invincible breathingtm · we will concentrate on achieving air hunger only. don’t be concerned...

INVINCIBLE BREATHING TM

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To complete the multiple-choice question exam, log into the Level 1 Instructor

portal to which you have a personalised login on OxygenAdvantage.com.

The exam can be completed in stages using the save and continue option.

Upon completion, please click on SUBMIT. You will receive your exam result within

a few minutes. Upon completion of exam, you will receive a digital certificate toteach Level 1 Oxygen Advantage.

Email: [email protected] with any questions regarding the technical

application of the Oxygen Advantage®.

OXYGEN RESEARCH INSTITUTE LTD.

Loughwell, Moycullen, Co. Galway, Ireland

W: OxygenAdvantage.com

E: [email protected]

Copyright © 2020 Patrick McKeown

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CONTENTS

SCRIPT OF MEASUREMENTS AND EXERCISES �� 6

Snapshot of Benefits ..................................................................7

Body Oxygen Level Test .............................................................9

1� Warm up with many small breath-holds ................................10

2a� Breathe Light – Biochemistry ...............................................13

2b� Breathe Light – Biomechanics .............................................17

2c� Breathe Light – Paced .........................................................19

2a,b,c Breathe Light ..................................................................21

3� Breath hold walking (5 to 10 paces) ......................................23

4� Breathe Light – Walking with a SportsMask 25

(5 minutes) ................................................................................25

5� Breathe Light – Walking, jogging/fast

walking with a SportsMask (5 minutes) ......................................30

6� Breathe Light Advanced (5 minutes) ......................................34

CHAPTER 1 ........................................................................ 39

Introduction to the Oxygen Advantage .....................................39

Screening for breathing pattern disorders in sports ..................44

The relationship between breathing patterns

and functional movement .........................................................47

Science of respiratory physiology ..............................................49

CHAPTER 2 ........................................................................ 61

Increasing oxygen uptake during

rest and physical exercise .........................................................61

Nose breathing .........................................................................63

Nasal breathing during physical exercise ..................................66

Nasal breathing workload during physical exercise ...................67

Exercise-induced asthma ...........................................................69

Addressing Exercise-Induced Bronchoconstriction (EIB) ............70

Improving sleep quality for focus and performance ...................71

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CHAPTER 3 ........................................................................ 80

BOLT (comfortable breath-hold time) measurement ��80

Heart rate variability ��81

Get in the Zone ��83

CHAPTER 4 ........................................................................ 88

Program based on BOLT score, age and state of health ��88

Tailoring exercises to individual athletes ��89

Nasal obstruction resulting in strong air hunger ��90

Training format week one to week four onward ��92

Teaching the Oxygen Advantage® ��95

FLIP CHART NOTES ........................................................... 99

Exercise 2a Breathe Light Biochemistry ��99

Exercise 2a,b,c Breathe Light �� 100

Breathing, Sleep, Emotions �� 101

Increase to Baroreceptor Sensitivity

Reduces Chemosensitivity �� 102

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DEFIN

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Definitions

Hemoglobin: protein found within the red cells and allows seventy times more

O2 to be carried in the blood.

SpO2: percentage of oxygenated hemoglobin versus total hemoglobin in arterial

blood.

Blood: made up of three parts: oxygen-carrying red cells, white blood cells and

plasma. 5 litres in adult.

Hematocrit: The ratio of the volume of red cells to the volume of whole blood

(plasma, red blood cells, white blood cells). Normal range is approximately 40%

to 50% for men and 37% to 44% for women.

Normocapnia: normal arterial CO2, which is about 40mmHg.

Hypocapnia: below normal arterial CO2, which is less than 37mmHg (recent figure

is 35mmHg).

Hypercapnia: abnormally elevated levels of CO2, which is levels greater than

45mmHg.

Tidal volume: the normal volume of air entering the lungs during one inhale at

rest.

Respiratory rate: The number of breaths usually calculated per minute.

Minute ventilation: the volume of air that enters the lungs over one minute.

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SCRIPT OF MEASUREMENTS AND EXERCISES

SCIENTIFICALLY PROVEN BREATHING TECHNIQUE TO IMPROVE PERFORMANCE

Oxygen Advantage® Level 1 Instructor Script

All exercises are performed by breathing with the nose only. The mouth should be kept gently closed throughout.

Important:

The Oxygen Advantage® workout is perfectly safe for the vast majority of

people.

Persons who suffer from panic attacks, anxiety, heart disease (if

there has been a recent heart attack, use relaxation without air shortage)

may experience stress from reducing breathing volume.

Please advise females attending your training not to do any of the

breathing exercises if they are (or are likely to be) in the first trimesterof pregnancy. This information is contained in the client intake form.

However, also mention it in class that, if pregnant, the expectant mother

should never do strong breath-holds as this will create a lot of stress for

both mother and baby. If a student is pregnant, discuss the importance of

avoiding over-breathing by not overeating, managing stress, relaxing, and

by breathing through the nose, etc. During any stage of pregnancy, the

BOLT should not increase by more than two seconds each week. For the

second trimester onward, only teach nasal breathing and gentle relaxation

with light air hunger.

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Snapshot of Benefits

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Overview:

1. Warm up with many small breath-holds (2.5 minutes)

2a. Breathe Light – Biochemistry (4 minutes)

2b. Breathe Light – Biomechanics (4 minutes)

2c. Breathe Light – Paced (4 minutes)

3. Breath hold walking (5 to 10 paces)

4. Breathe Light – Walking (5 minutes)

5. Breathe Light – Walking, jogging/fast walking (5 minutes)

6. Breathe Light Advanced (5 minutes)

L E T ’ S G E T S TA RT E D !

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Take a normal, silent breath in through your nose

Allow a normal, silent breath out through your nose

Hold your nose with your fingers to prevent air from entering your

lungs

Count the number of seconds until you feel the first distinct desire to

breathe in

Body Oxygen Level Test

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1. WARM UP WITH MANY SMALL BREATH-HOLDS

Objective:

The objective of this exercise is to gently prepare the body for a tolerable

feeling of breathlessness. By holding the breath for short periods of

time, the gas nitric oxide (NO) pools inside the nasal cavity, and the gas

carbon dioxide (CO2) slightly increases in the blood. Upon resumption of

breathing, breathe in so as to carry NO from the nasal cavity into the lungs.

As you hold your breath, you may feel a light hunger for air. This signifies

that the CO2 is increasing in your blood. Both gases play an important

role in opening the airways, improving blood circulation and allowing

more oxygen to be delivered to the cells. This exercise is ideal to help

reduce stress, asthma symptoms and breathing recovery following physical

exercise.

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Results:

Introduce air hunger

Harness nasal nitric oxide

Calming exercise in times of stress

Emergency exercise to help with asthma, panic attacks and hyperventilation

Suitable for all persons.

Script:

Let’s begin by holding the breath for five seconds, followed by normal breathing for ten seconds or so.

Instruction:

Take a normal breath in and out through the nose.

Pinch your nose with your fingers to hold the breath for five seconds.

5,4,3,2,1.

Let go of your nose and breathe in and out through your nose for ten

seconds.

Just breathe as normal for ten seconds.

And again, take a normal breath in and out through your nose. Pinch

your nose with your fingers to hold your breath for five seconds.

5,4,3,2,1.

When you let go, breathe in through your nose.

Breathe as normal for ten seconds. Don’t make any changes to your

breathing. Just breathe as normal.

And again, take a normal breath in and out through your nose. Pinch

your nose with your fingers to hold your breath for five seconds.

5,4,3,2,1.


Breathe as normal for ten seconds.

As you hold your breath, nitric oxide pools inside the nasal cavity.

Breathing in after the breath-hold will carry nitric oxide into the lungs.

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There, it will help open the airways and improve oxygen uptake in the

blood.

You should not feel stressed while doing this exercise. If the air hunger

is too much, then hold the breath for three seconds only.

Repeat:

And again, normal breath in through your nose, normal breath out

through your nose and pinch your nose.

5,4,3,2,1.


Breathe normally for about ten seconds.

And again, normal breath in through your nose, normal breath out

through your nose and pinch your nose.

5,4,3,2,1.


Breathe normally for about ten seconds.

For persons with BOLT score of less than ten seconds, high stress levels,

panic disorder and COPD; repeat this sequence for ten minutes every

hour.

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2A. BREATHE LIGHT – BIOCHEMISTRY

Objective:

This exercise helps to normalize breathing biochemistry. It involves

reducing the volume of air you are taking into your body in order to create

a tolerable hunger for air. This is the feeling that you would like to take a

slightly bigger breath or the feeling that you are not quite getting enough

air. When you breathe less than before you started the exercise, a feeling

of “air hunger” is created. Achieving a slight or tolerable air hunger

signifies that carbon dioxide has accumulated in the blood.

One of the functions of carbon dioxide is to act as a catalyst for the

release of oxygen from the red blood cells. Breathing slowly and lightly

also enables nitric oxide to accumulate in the nasal cavity and travel

to the lungs. Upon reaching the lungs, it diffuses into the blood and

performs its miracle work throughout the lungs. With gentle, light and

soft breathing, the blood vessels open, and more oxygen is released from

the red blood cells to feed your tissues and organs. With this exercise,

we will concentrate on achieving air hunger only. Don’t be concerned

about breathing using the diaphragm. It doesn’t matter at this point. If

you are already doing so, then great. If not, that’s fine. Just concentrate on slowing down the breath, quietening the breath and softening the breath.

The objective is to sustain a tolerable air hunger for approximately four

minutes. If the air hunger is too much, then take a rest for twenty seconds

and return to it.

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Results:

Improves oxygen uptake and delivery

Harnesses nasal nitric oxide

Reduces sensitivity to carbon dioxide accumulation

Normalizes breathing volume

Acts as a meditation to anchor the mind to the breath

Improves concentration

Suitable for all except those with serious health conditions and those in

the first trimester of pregnancy.

Script:

Posture

Sit on a chair, take the lotus position, or lie on your back in a semi-

supine position.

If sitting, imagine a piece of string gently pulling you upward toward

the ceiling.

Imagine and feel the space between your ribs widening.

With your mouth closed and jaws relaxed, breathe normally in and out

through your nose.

Place your hands on your chest and tummy or on your lap.

Awareness of breathing

Observe your breath as it enters and leaves your nose. Focus on the

airflow as it moves in and out of your nose. Feel the slightly colder air

entering your nose and feel the slightly warmer air leaving your nose.

Really concentrate on the air as it enters and leaves your nose.

Use this as a measure of your concentration. For how long can you

hold your attention on your breath before your mind wanders? If you

notice the mind wandering a lot, this exercise will considerably help

improve your concentration.

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Bring attention to your breathing. It is normal for the mind to wander

during this exercise. As soon as you notice the mind wandering, bring

your attention back to your breathing.

You may feel your chest move up and down, or you might feel your tummy move in and out. At this point, don’t try to adjust anything. Simply become aware of your breathing.

Instruction

When you are able to follow your breathing, take a slow breath in

through the nose and allow a slow, gentle, relaxed breath out. Slow

down the speed of the air as it enters and leaves your nose. Breathe in

a slow and gentle manner. Breathing should be so light, quiet and still.

Slow down your breathing so that you feel hardly any air entering and

leaving your nostrils. Your breathing should be so quiet that the fine

hairs within your nostrils do not move.

Breathe so lightly that there is hardly any turbulence inside your nose.

At the top of the inhale, bring a feeling of total relaxation to your

body and allow a slow, soft, relaxed breath out. The air should leave

your body slowly and effortlessly.

It is very important not to consciously interfere with your breathing

muscles or restrict your breathing during this exercise. Don’t tense

your stomach to reduce your breathing.

Your breathing volume should now be less than what it was before you

started the exercise.

Create air hunger

The goal is to feel a want or “hunger” for air. To have a feeling that

you would like to take in a bigger breath.

Once again, take a very slow breath in, almost as if you are not

breathing.

As you breathe out, bring a feeling of relaxation to the body, allowing

the air to leave the body effortlessly.

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A slow breath in.

And a relaxed breath out.

By taking a slower breath in and allowing a relaxed, slow breath out,

carbon dioxide accumulates in the blood. This creates a feeling that

you would like to take in more air.

This is valuable feedback that you are performing the exercise

correctly and reducing your breathing volume toward normal.

Repeat

It is normal for the mind to wander. As soon as you notice the mind

wandering, bring your attention back to your breathing.

Once again, take a slower breath into your lungs.

As you breathe out, bring a feeling of total relaxation to the body,

allowing the air to leave the body effortlessly.

The air hunger you feel during this exercise should be tolerable.

If you notice that your breathing rhythm is getting fast or chaotic, then

the need for air is too much.

In this case, stop the exercise and breathe normally for half a minute,

then resume gentle, light breathing to create a tolerable need for air.

Don’t deliberately interfere with your breathing muscles. Don’t hold

your breath. Don’t freeze your breathing. Instead, allow your breathing

to soften with a very slow breath in and a gentle, relaxed, slow breath

out.

Once again, take a slow breath into your lungs.

As you breathe out, bring a feeling of total relaxation to the body,

allowing the air to leave the body effortlessly.

So now, take a rest for a minute and breathe as normal as we move

onto Breathe Light Biomechanics.

Continue with this instruction for approximately four minutes.

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2B. BREATHE LIGHT – BIOMECHANICS

Objective:

The diaphragm breathing muscle is important for postural control, and it

functions through its generation of intra-abdominal pressure (IAP). During

inhalation, the diaphragm moves downward and IAP is generated. Similar

to an inflated balloon, this has a stabilizing effect and provides support

for the spine and pelvis. Immediately prior to a lift, a weight lifter will

breathe in and hold her breath to generate high levels of IAP to “stiffen

the spine”. Functional breathing patterns generate more optimal IAP and

spinal stiffness to help ensure postural support during movement. When

breathing patterns are healthy, there is lateral expansion of the lower rib

cage. This only occurs if there is sufficient generation of IAP acting through

the zone of apposition “to push the ribs out” (Key, 2013).

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Results:

Diaphragmatic breathing helps enable slow breathing

Diaphragmatic breathing helps calm the mind

Improves gas exchange as air is drawn deep into the lungs

Supports functional breathing for functional movement

Generates intra-abdominal pressure for postural control and spinal

stabilization

Script:

Posture

Imagine a piece of string gently pulling you upward toward the ceiling.

Imagine and feel the space between your ribs widening.

Instruction

Place your hands on either side of your body at your lower two ribs. I

would like you to bring the air deep into your lungs. As you breathe in,

feel your ribs expanding outward. As you breathe out, feel your ribs

moving inward.It takes intra-abdominal pressure to push the ribs outward. Take fuller

breaths but fewer of them. A larger tidal volume (fuller breath) will stimulate the vagus nerve. Again, as you breathe in, feel your lower ribs moving outward, and as you breathe out, feel your lower ribs moving inward.Ideally, during an inhalation, as the diaphragm moves downward and the intercostal muscles move outward, this generates outward movement to the front (abdominal), sides and back.As you breathe in, feel your ribs expanding outward. As you breathe

out, feel your ribs moving inward.There is no need to hear your breathing during this exercise. Breathe

slowly, lightly and deeply.


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2C. BREATHE LIGHT – PACED

Objective:

As the BOLT score increases, the respiratory rate naturally decreases and

the natural pause following exhalation increases. When the BOLT score

is forty seconds, the typical respiratory rate is six to eight breaths per

minute. Changing the cadence of breathing to six breaths per minute helps

provide numerous benefits, including improved breathing efficiency. With a reduced respiratory rate, a greater volume of air per minute arrives at the

alveoli (small air sacs in the lungs where gas exchange takes place). This is

because less volume of air per minute is lost to “dead space”.

There is a substantial body of research supporting improved heart

rate variability (HRV) for a variety of disorders and for performance

enhancement. Both HRV and baroreflex sensitivity are maximized when respiration is slowed to six breaths per minute. A cadence of six breaths

per minute also helps to reduce chemosensitivity to carbon dioxide,

resulting in a higher BOLT score. For persons with a strong fear of

suffocation, cadence breathing may be a better option as increased carbon

dioxide is better tolerated, resulting in a reduced fear response.

The synchronicity of HRV and respiration is called respiratory sinus

arrhythmia (RSA). In a healthy person, the heart rate increases during

inspiration and decreases during expiration. Respiratory sinus arrhythmia

can indicate functioning of the autonomic nervous system, and according

to author Stephen Porges, it is an index of parasympathetic tone. Greater

vagus nerve traffic will increase RSA. Slowing down the respiratory rate will naturally result in an increased tidal volume. This, along with diaphragmatic

breathing, significantly increases RSA.

Results:

Optimizes ventilation

Improves breathing efficiencyIncreases gas exchange in the lungs

Maximizes vagal tone

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Maintains parasympathetic-sympathetic balance

Increases HRV and RSA

Improves mental and physical resilience

The ideal timing of each breath is an inhalation for four seconds and an

exhalation for six seconds. Using a stopwatch, co-ordinate your clients’

breathing so that they breathe in for four seconds and allow a relaxed

breath out for six seconds.

The verbal instruction I typically give when teaching this exercise is:

Instruction

I would like you to place your hands on your lower two ribs.

As you breathe in, feel your ribs moving outward, and as you breathe out, feel your ribs moving inward.To pace your breathing, I would like you to breathe in for a count of

four seconds, and to breathe out for a count of five seconds, and to pause for one second.

In 2, 3, 4 (timed for four seconds), out 2, 3, 4, 5. (timed for five seconds) (Pause for one second)In 2, 3, 4, out 2, 3, 4, 5.(Pause for one second)In 2, 3, 4, out 2, 3, 4, 5. (Pause for one second)In 2, 3, 4, out 2, 3, 4, 5.Please continue breathing in this manner for the next couple of minutes.

Breathing in for a count of four seconds and breathing out for a count

of five seconds, and to pause for one second.As you breathe in, feel your ribs moving outward, and as you breathe out, feel your ribs moving inward.


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2A,B,C BREATHE LIGHT

Bring all three together:

Light 2a: Breathing slightly less air to create a light air hunger.

Slow 2c: Do not take so many breaths per minute. Pace your breathing

to six breaths per minute during rest.

Deep 2b: Feel your lower ribs expanding and contracting with each

breath.

Instruction

I would like you to place your hands on your lower two ribs.

Slow down the speed of the air as it enters and leaves your nose. Your breathing should be light, quiet and still.

Light Slow Deep

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At the top of the inhale, bring a feeling of relaxation to your body and

allow a slow, soft, relaxed breath out. The air should leave your body slowly and effortlessly.

With each inhalation, take the air deep into the lungs.

As you breathe in, feel your ribs expanding outward. As you breathe

out, feel your ribs moving inward. The cue throughout the exercise is light, slow and deep.

In 2, 3, 4 (timed for four seconds), out 2, 3, 4, 5. (timed for five seconds) (Pause for one second)In 2, 3, 4, out 2, 3, 4, 5.(Pause for one second)In 2, 3, 4, out 2, 3, 4, 5.(Pause for one second)In 2, 3, 4, out 2, 3, 4, 5.Breathe light, slow and deep.


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3. BREATH HOLD WALKING (5 TO 10 PACES)

Objective:

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Suitable for persons with stress, asthma, or those prone to panic attacks.

Suitable for all except those with serious medical conditions and pregnant

women.

Script:

Take a normal breath in and out through your nose.

Hold your breath and walk for five to ten paces.Stop walking and release your nose. Breathe in through your nose and

resume gentle breathing in and out of your nose.

Wait for thirty to sixty seconds and repeat.

And again. Take a normal breath in and out through your nose. Pinch

the nose with your fingers and walk five to ten paces while holding your breath.

Stop walking and release your nose. Breathe in through your nose and

resume gentle breathing in and out of your nose.

Wait for thirty to sixty seconds and repeat.

Repeat five times.

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4. BREATHE LIGHT – WALKING WITH A SPORTSMASK

(5 MINUTES)

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Objective:

The objective here is to take the Breathe Light exercise into physical

movement. Breathe light, slow and deep. During physical exercise, carbon

dioxide is generated through increased metabolic activity. As you walk,

bring your attention to your breathing. Feel your breathing, follow your

breathing and gently slow it down. This is a walking meditation. The

objective is to breathe slowly by breathing fewer breaths per minute, to

breathe lightly by creating a tolerable air hunger, and to breathe deeply

by feeling lateral expansion and contraction of the lower two ribs. Wearing

a SportsMask will slow down your breathing and generate a feeling of air

hunger through that resistance. To help counter the feeling of air hunger

while wearing the mask, it is easier if you breathe only through the nose,

slowly and deeply. In other words, the mask provides biochemical and

biomechanical breathing practice.

Results:

Aids recovery from the previous exercise

Improves functional breathing during walking

Increases oxygen uptake in the blood

Reduces the sensitivity of the body to carbon dioxide build-up

Improves breathing efficiency by taking fewer breaths per minute

Allows the experience of physical movement while breathing through

the nose

Prepares the body for faster-paced exercise with nose breathing

Helps you pay attention to your breathing during walking (a walking

meditation)


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Script:

Posture

Begin by walking at a moderate pace with your mouth closed.

As you walk, bring your body upright. Imagine the space between your

ribs widening. Keep your eyes looking directly ahead. Do not look up

or down.

Awareness

I would like you to take your attention from your mind and place it on

your breath.

Concentrate on your breathing. Focus on your breathing.Use this as a measure of your concentration. For how long can you hold your attention on your breath?

Feel the air coming into your nose and feel the air leaving your nose.Once again, concentrate on the air coming into your nose and leaving your nose.

It is normal that your mind will wander during this exercise. Each time

it does, gently bring your attention back to your breath.

Biochemistry (continue to Biomechanics if wearing a SportsMask)The objective is to breathe lightly during your walk, to breathe less air than you normally would, and to feel a hunger for air.

As you feel the air entering and leaving your nostrils, gently soften your breathing.

As you continue to walk, slow down the speed of the air as it enters

your nostrils.

Slow down the speed of the air as it leaves your nostrils.Take a slow and gentle breath in and allow a relaxed, gentle breath

out.

Breathe softly so that the fine hairs within your nostrils do not move.Breathe softly to allow nitric oxide pool to inside the nasal cavity, to be carried to the lungs.

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There it will help to open the airways and improve oxygen uptake in the blood.

Slow down the speed of your in-breath and allow a gentle, relaxed

breath out.

As you slow down your breathing, carbon dioxide increases to allow

more oxygen to be released into the cells.

Block one nostril (continue to Biomechanics if wearing a SportsMask)(After a couple of minutes walking) Now, I would like you to block one of your nostrils with your finger.It doesn’t matter which nostril you block.

This will concentrate the air entering and leaving your nose.Soften your breathing as you breathe through one nostril. The

objective is to create a tolerable need for air, to feel slightly breathless, and to want to take in more air.

Bring your complete and undivided attention to your breathing.It is normal for the mind to wander.

When your mind wanders, bring your attention back to your breath.

Biomechanics

Place your hands at your sides and feel your lower two ribs.

As you breathe in, feel your ribs moving outward.As you breathe out, feel your ribs moving inward.Breathe light, slow and deep.

Reduce the number of breaths per minute and allow each breath to be

deeper.

Take fuller breaths, but fewer of them.

As you breathe in, feel your lower ribs moving outward, and as you breathe out, feel your lower ribs moving inward.Ideally, during inhalation, as the diaphragm moves downward and the intercostal muscles move outward, this generates outward movement to the front (abdominal), sides and back. It takes intra-abdominal pressure to push the ribs outward.

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As you breathe in, feel your ribs expanding outward. As you breathe

out, feel your ribs moving inward.Repeat for the duration of the exercise

The objective is to breathe light, slow and deep during your walk, to breathe less than you normally would, and to feel a hunger for air.

Light: breathe less to create a tolerable air hunger (wearing aSportsMask will naturally create a resistance to breathing and createair hunger).Slow: don’t take so many breaths per minute.

Deep: as you breathe in, feel your lower two ribs move outward, and as you breathe out, feel your lower two ribs move inward.Focus on your breathing, feel your breathing, follow your breath.Bring your complete and undivided attention to your breathing.It is normal for the mind to wander.

When your mind wanders, bring your attention back to your breath.

Continue this exercise for five minutes.

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5. BREATHE LIGHT – WALKING, JOGGING/FAST WALKING WITH

A SPORTSMASK (5 MINUTES)

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Objective:

This exercise involves jogging with the mouth closed for one minute,

followed by walking for one minute. While this exercise is a challenge, it

should not be stressful. The objective is to push yourself, but not to lose

control of your breathing. For those unable to jog, fast walking will suffice.

Results:

Helps generate carbon dioxide by engaging in physical exercise

Improves functional breathing during physical movement

Helps strengthen the breathing muscles

Helps reduce breathlessness and condition the body to tolerate

increased arterial carbon dioxide

Improves breathing efficiency during physical movement


Script:

Instruction

Increase the pace to a fast walk or jog.

Continue for one minute.

Jog for one minute

Now I would like you to increase the pace to a fast walk or light jog. Go at a pace where you can maintain nasal breathing.

It should be a slight challenge, but it should not be stressful.

Continue to breathe in and out through your nose.

Don’t hold your breath. Don’t freeze your breathing. Just breathe

gently in and out through your nose.

Focus on your breathing. Feel the air as it enters your nose and feel the air as it leaves your nose.The objective is to breathe light, slow and deep during your jog, to breathe less than you normally would, to feel a hunger for air.

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Light: breathe softly to create a non-stressful air hunger. Wearing a

SportsMask will naturally create a resistance to breathing and createan air hunger.

Slow: don’t take so many breaths per minute.

Deep: as you breathe in, feel your lower two ribs move outward, and as you breathe out, feel your lower two ribs move inward.Breathe fewer breaths, but fuller breaths. Take the air deep into your

lungs.

Focus on your breathing, feel your breathing, follow your breath.If the feeling of air hunger is too strong, then adjust the setting on

your mask to increase the airflow. Now I would like you to slow down to a walk.

Walk for one minute. Minimal breathing for six breaths (no need to

minimize breathing if wearing the mask)

As you walk, minimize your breathing for six breaths.

Take very short breaths in and out of your nose. Just take a flicker of air in and a flicker of air out. Take in enough air to fill your nostrils and no more. Breathe less than you would when breathing normally.

The objective is to create an air hunger. You should feel that you are not getting enough air.

Recover breathing for 12 to 18 breaths

Now, breathe as normal for 12 to 18 breaths.

As you breathe in, feel your lower two ribs move outward, and as you

breathe out, feel your lower two ribs move inward.

As you walk, take your attention out of your mind and place it on your

breath.

I would like you to concentrate on your breathing. Focus on your

breathing. Make your walk a meditation.

Feel the air coming into your nose and feel the air leaving your nose.

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It is normal for the mind to wander. If your mind wanders, gently bring

your attention back to your breathing.

Follow your breath. Feel your breathing. Take your attention out of your head and place it on your breathing. Feel the air coming into your nose and feel the air leaving your nose.

Jog for one minute, walk with minimal breathing for six breaths, then

breathe normally for twelve to eighteen breaths. Continue this exercise

for five minutes.

1. Jog one minute 2. Walk one minute

3. Jog one minute 4. Walk one minute

5. Jog one minute

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6. BREATHE LIGHT ADVANCED (5 MINUTES)

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Objective:

This exercise can be performed while sitting or lying on the back in a

semi-supine position. The goal of this exercise is to breathe lightly while

using the diaphragm. It is easier to activate abdominal breathing while

lying on your back in a semi-supine position. With this simple exercise,

you can reduce your breathing movements by 20 to 30 percent. If your

stomach muscles start to feel tense, contract or jerk, or if your breathing

rhythm becomes disrupted or out of control, then the air hunger is too

intense. In this situation, stop practicing the exercise for fifteen seconds or

so and then return to it. The most common mistake is to deliberately tense

the muscles of the chest or abdomen to restrict breathing movements.

If you find this happening, then take a break from the exercise for fifteen

seconds or so. When you return to it, encourage your breathing to reduce

by exerting gentle pressure on your chest and abdomen with your hands,

encouraging your breathing to slow using relaxation rather than force.

Do not be concerned about the number of breaths you take per minute.

Ideally, this should not increase. However, if your BOLT score is less than

twenty seconds, you may find that your breathing rate increases during

the exercise. If this happens, try to slow down your breathing and keep it

calm. As your BOLT score increases, it will become much easier to maintain

control of your breathing during reduced-breathing exercises.

At first, you may only be able to maintain an air hunger for twenty seconds

before the urge to breathe is too strong. With practice, you will be able

to maintain an air hunger for longer periods. Remember, you are trying to

create an air hunger that is tolerable but not stressful. Aim to maintain this

tolerable air hunger for three to five minutes at a time. During reduced-

breathing exercises, it is vital that you create a hunger for air in order to

bring about an accumulation of carbon dioxide in the blood. When this

happens, the respiratory center in the brain is reset to a calmer and more

normal breathing volume.

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Results:

Enhances recovery

Improves functional breathing

Activates the diaphragm

Normalizes breathing volume

Acts as a meditation as it brings attention to the breath

Script:

Lie on a mat with a small pillow under your head and knees bent, as shown

above.

Activate the diaphragm

Place a book or hand just above your navel.Concentrate on breathing into the abdomen.

Breathe in, gently guide the book or hand upward.

Breathe out, gently guide the book or hand downward.

While breathing in, imagine inflating your belly with a light amount of air and watch your hand rise. While breathing out, imagine a balloon

slowly deflating of its own accord.

Breathe Light

When you are able to breathe using your diaphragm, focus on taking a

slow breath into the nose. Slow down the speed of the air as it enters

and leaves your nose.Breathe in a slow and gentle manner. Breathing should be so light,

quiet and still.

Slow breath in.

Slow, gentle breath out.

At the top of the inhale, bring a feeling of relaxation to your body and

allow a slow, soft, relaxed breath out.

Breathe in, hand rises.

Breathe out, hand falls.

Take a light, slow and deep breath in.

Allow a slow, gentle breath out.

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Don’t interfere with your breathing muscles or restrict your breathing.

Don’t tense your stomach to reduce your breathing.

Just allow your breath to soften, to relax, to go still.

Experience air hunger

The objective is to feel a want or hunger for air. To have a feeling that you would like to take in a bigger breath.

Once again, take a light, slow and deep breath in.


the air to leave your body effortlessly.Breathe in, gently guide your hand upward.

Breathe out, gently guide your hand downward.

With gentle, light and soft breathing, the blood vessels open, allowing more oxygen to be released into the tissues and organs.

Continue in the same way: light, slow and deep breath in, relaxed

breath out. Light, slow and deep breath in, relaxed breath out.

Allow the body to relax, allow the breath to relax, allow your breathing

to soften.

Breathing should be quiet, calm, regular, gentle and easy. Slowing

down the exhalation brings the body into relaxation.

Repeat

Breathe in, gently guide your hand upward.

Breathe out, gently guide your hand downward.

It is normal for the mind to wander. As soon as you notice the mind

wandering, bring your attention back to your breathing.

Once again, take a light, slow and deep breath into your lungs.


the air to leave the body effortlessly.Continue in the same way: light, slow and deep breath in, relaxed




The air hunger you feel during this exercise should be tolerable.

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Create a tolerable air hunger

If you notice that your breathing rhythm is getting fast or chaotic, then

the need for air is too much.

In this case, stop the exercise and breathe normally for half a minute,

then resume gentle, light breathing with your hands against your chest

and tummy to create a tolerable need for air.

Don’t deliberately interfere with your breathing muscles. Don’t hold

your breath. Don’t freeze your breathing. Instead, allow your breathing

to soften with a shorter breath in and a gentle, relaxed, slow breath

out.

Continue in this manner. A light, slow and deep breath in and a gentle,

relaxed breath out.

Continue breathing softly and maintain the feeling that you are not

getting enough air, that you would like to take in more air, that you

feel a deprivation of air.As you soften your breathing with a slow breath in and a gentle,

relaxed breath out, the gases nitric oxide and carbon dioxide will open

your airways and blood vessels, allowing more circulating oxygen and improved oxygen delivery to your tissues and organs including the heart and brain.

Once again, take a light, slow and deep breath into your lungs.


the air to leave the body effortlessly.Continue in the same way: light, slow and deep breath in, relaxed




Take home message:

Advice on how to achieve optimal breathing in everyday life: keep your

mouth closed during the day, during sleep, and during physical exercise.

Pay attention to your breathing at different times throughout the day. Aim

to spend one hour daily softening your breath, quietening your breath and

feeling tolerable air hunger.

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CHAPTER 1

INTRODUCTION TO THE OXYGEN ADVANTAGE

Functional Breathing Pattern Training

Improves blood circulation and oxygen delivery to the cells

Dilates the upper airways (nose) and lower airways (lungs)

Reduces the onset and endurance of breathlessness

Significantly reduces exercise-induced bronchoconstriction Reduces energy cost associated with breathing

Maximises vagal tone

Maintains parasympathetic–sympathetic balance

Increases HRV, RSA and sensitivity of baroreceptors

Improves sleep, focus, concentration and calm

Improves posture and spinal stabilization

Improves functional movement to reduce the risk of injury

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Traits of Dysfunctional Breathing:

Breathing through the mouth

Upper chest movement

Hearing breathing during rest

Frequent sighing

Frequent yawning

Paradoxical breathing

Easily noticeable breathing movement during rest

There is no precise definition of dysfunctional breathing patterns, but it generally includes any disturbance to breathing, including hyperventilation

or over-breathing, unexplained breathlessness, breathing pattern disorder

and/or irregularity of breathing.

Minute ventilation is the volume of air taken into the body per minute. It is

calculated by multiplying the respiratory rate by the tidal volume. Normal

minute ventilation is four to six liters.

Hyperventilation is breathing in excess of the metabolic requirements of

the body at that time to cause hypocapnia. Hypocapnia is a lower than

normal pressure of carbon dioxide in the blood. Breathing a volume of

air in excess of what the body requires removes too much carbon dioxide

from the blood through the lungs.

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Breathing to evoke relaxation

Slow down breathing

Regular breathing

Soft breathing

Nose breathing

Diaphragmatic breathing

The above traits that bring the body into relaxation are the same traits of

healthy and functional breathing patterns during rest.

How should we breathe?

Healthy breathing is light, quiet, effortless and soft. Breaths are through

the nose, diaphragmatic, rhythmic and gently paused on the exhale. This

is how human beings breathed until the comforts of modern life changed

everything, including our breathing. If you took a run alongside an elite

athlete in good health, would you expect her to be huffing and puffing like a train?

Stress affects breathing in the following ways:

It becomes faster

Sighing becomes more frequent (breathing becomes irregular)

Breathing becomes more noticeable

Oral breathing

Upper chest breathing

The breathing pattern while the body is under stress displays similar traits

to breathing pattern disorders.

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BOLT (COMFORTABLE BREATH-HOLD TIME) MEASUREMENT:



Hold your nose with your fingers to prevent air from entering your lungs

Count the number of seconds until you feel the first distinct desire to breathe in

Notes on the body oxygen level test (BOLT):

Holding of the breath until the first definite desire to breathe is not influenced by training or behavioral characteristics. Instead, it can be deduced to be a more objective measurement of breathlessness

(Nishino, 2009).

Voluntary breath-holding duration is thought to provide an indirect

index of sensitivity to CO2 build-up.

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SCREENING FOR BREATHING PATTERN DISORDERS IN SPORTS

The presence of dysfunctional breathing (DB) does not reflect an individual’s level of cardiovascular fitness. Sub-optimal breathing during rest also means sub-optimal breathing during exercise. Research has linked

dysfunctional breathing (DB) to a host of health conditions, including

lower back pain and neck pain. It has also been proven to adversely

affect the musculoskeletal system (Kiesel et al.,2017). For example,

in an study of rowers, 25 percent reported that they did not attend a

training session because of lower back pain (Bahretal., 2004). Breathing

is one of the body’s most vital functions, so when breathing patterns

become sub-optimal, other functions, such as core muscle function, will

compensate to help maintain respiration. As such, researchers conclude

that core muscle function is significantly different in those who suffer from dysfunctional breathing. Core muscle dysfunction is now correlated with

a variety of musculoskeletal problems, such as lower back pain, neck

pain and ACL injuries, and there is also an overall increased risk of injury.

When rehabilitating patients, core muscle exercises are often prescribed.

However, despite all that is known about breathing function in this regard,

it remains mostly overlooked by medical professionals. (Kiesel et al., 2017).

Breathing pattern disorders are multi-dimensional. They are made up

of a series of biochemical, biomechanical and psycho-physiological

components, so they cannot be definitively diagnosed with a single test. Instead, a comprehensive breathing screening procedure was

developed by Kiesel et al., so that fitness and healthcare providers could accurately identify the existence of disordered breathing in patients (Kiesel

etal.,2017).

The study consisted of:

51 subjects (27 females, 24 males, 27.0 years, BMI 23.3)

Biochemical dimension using end-tidal CO2 (ETCO

2)

Biomechanical dimension using the Hi-Lo test

Psycho-physiological dimension using the self-evaluation of breathing

symptoms questionnaire (SEBQ) and Nijmegen questionnaires (Kiesel

et al., 2017).

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This method that assesses the biochemical aspect of respiratory function

is called capnography. Capnography measures a person’s average CO2

partial pressure at the end of exhalation, also known as end-tidal CO2

(etCO2). In comparison with arterial CO

2 measures, etCO

2 has high validity.

For the average person, the normal range is between 35-40mmHg, and

values of <35mmHg typically indicate the presence of a breathing pattern

disorder (Bradley & Esformes, 2014).

Kiesel et al’s investigation did not find a strong correlation between the

three measures (biochemical, biomechanical and psycho-physiological) of

disordered breathing. Five of the study’s participants were deemed to have

normal breathing, fourteen of them failed at least one measure, twenty

participants failed at least two of the measures, and twelve failed all three

(Kiesel et al., 2017). Among those with dysfunctional breathing patterns,

the ability to hold the breath is a function that is typically disturbed.

The inability to hold the breath for more than twenty seconds generally

indicates that a breathing pattern disorder is present. Additionally, it has

been proposed that resting CO2 levels correlate with breath hold time.

The study by Kiesel et al. concluded that a combination of four questions

from the functional movement screening and a breath-hold time of

twenty-five seconds can be used to screen for the presence of disordered

breathing. To accurately measure breath-hold time (BHT), the individual is

directed to hold their breath, beginning at the end of a standard exhale

(functional residual capacity). The breath-hold is measured until the tester

notes the participant’s first involuntary activity or a contraction of the

breathing muscles (diaphragm or throat). (Kiesel et al., 2017) This is the

same as the BOLT measurement.

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The four questions from the functional movement test that were

included in the study were:

Do you feel tense?

Do you feel a cold sensation in your hands or feet?

Do you notice yourself yawning?

Do you notice yourself breathing through your mouth at night?

In the study, the researchers conclude that if an individual passes

this screening, there is an 89 percent chance that they do not have

dysfunctional breathing. However, if the person does not pass the

screening, further assessment is advised (Kiesel et al., 2017).

Breathing pattern disorder in sports

A combination of thoracic breathing and excessive minute ventilation can

cause significant issues for respiratory chemistry. In particular, it can trigger a decrease in the carbon dioxide levels of the bloodstream. In response,

the pH of the blood increases, thus creating a state of respiratory alkalosis.

Respiratory alkalosis can activate changes in the body’s physiological,

psychological and neuronal states, which can have a detrimental effect on

a person’s health and performance, as well as their musculoskeletal system

(Bradley & Esformes, 2014).

In addition to chemical changes in the body, individuals with respiratory

alkalosis also report an array of symptoms, such as exhaustion, headaches,

dizziness, light sensitivity, trouble sleeping, chest pain, cramps, and

feelings of breathlessness. For an athlete participating in physical activity,

the presence of an abnormal breathing pattern can manifest as premature

breathlessness or muscle fatigue, which inevitably results in sub-optimal

performance (Chapman et al., 2016).

Another aspect to consider is the important role of normal breathing

mechanics in posture and spinal stabilization. Studies have shown

that breathing pattern disorders (BPDs) can cause increased pain and

contribute to motor control deficits, thus causing dysfunctional movement

patterns (Bradley & Esformes,2014).

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THE RELATIONSHIP BETWEEN BREATHING PATTERNS AND

FUNCTIONAL MOVEMENT

In 2014, Bradley and Esformes conducted a study on the relationship

between breathing pattern disorders and functional movement. Thirty-

four healthy men and women participated. The results showed that

the subjects’ resting etCO2 and resting respiratory rate were the most

sensitive measures of breathing pattern disorders. In total, 70 percent of

the subjects were identified as having disordered results, and between 50

percent and 60 percent had abnormal scores (Bradley & Esformes, 2014).

According to Bradley and Esformes, functional movement is defined as

the ability to produce and maintain sufficient mobility and stability along

the kinetic chain while accurately and efficiently completing fundamental

movement patterns (Bradley & Esformes, 2014).

Mean Min Max

Rest etCO2 (mmHg) 33.70 ± 2.74 27.70 39.33

Rest RR (breaths/min) 18.39 ± 3.41 12.25 25.2

Active RR (breaths/min) 24.30 ± 3.06 17.65 30.64

BHT (sec) 19.22 ± 5.05 10.57 34.13

Nijmegen questionnaire 9.24 0.00 27.00

(Bradley & Esformes,2014)

For those who demonstrate sub-optimal movement patterns, the

functional movement screen (FMS) has been proven to accurately predict

injury. (recent opinion from physical therapists is questioning the accuracy

of the FMS) Additionally, subjects who achieved higher scores on the

Nijmegen questionnaire also had a higher RR and a lower etCO2 during

the FMS™ test. Individuals with a high respiratory rate had lower etCO2

measurements.

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When comparing diaphragmatic breathers and thoracic breathers,

interestingly, etCO2 measurements at rest were significantly higher for the

former (diaphragmatic: mean=35.47mmHg) than for the latter (thoracic:

mean=32.14mmHg). The research also revealed that a higher etCO2 was

positively correlated with a higher FMS™ score (Bradley & Esformes, 2014).

The correlation between breathing pattern disorders and functional

movement was also proven, as subjects with poor breathing patterns

scored lower on the FMS test. In total, 87.5 percent of those who passed

the FMS test were classified as diaphragmatic breathers. These results demonstrate the importance of functional breathing patterns for functional

movement (Bradley & Esformes, 2014).

According to Chapman et al., new neural connections can be made in

order to correct or re-educate disordered breathing patterns and restore

the central nervous system’s normal motor control patterns. “If breathing

is not normalized, no other movement pattern can be” (Chapman et al.,

2016).

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SCIENCE OF RESPIRATORY PHYSIOLOGY

Carbon dioxide production in the human body is about 200ml per minute.

It is produced as a by-product of cellular respiration, where food (glucose,

fats and proteins) and oxygen meet to provide energy for the body.

The regulation of breathing is determined by receptors in the

brainstem which monitor the concentration of carbon dioxide (CO2),

pH level, and, to a lesser extent, oxygen of the blood. Among these,

CO2 provides the strongest stimulus to ventilation. For example, a

slight increase (e.g., 2-5mmHg) in arterial blood pCO2 can more than

double the ventilation (Rassovsky, Adams & Kushner, 2006).

There is a large reserve of oxygen in the bloodstream, such that

oxygen levels must drop from 100mmHg to about 60mmHg before

the brain stimulates breathing (Loeschcke, Koepchen & Gertz, 1958),

which is reached during exercise at an altitude of about 2500m

(Ferretti et al., 1997; Woorons et al., 2007).

CO2 in the blood is carried in three ways:

5 percent dissolved in plasma

30 percent combined with blood proteins

65 percent converted to bicarbonate ions for its transportation in the

blood

The central chemoreceptors control regular breathing. They are located

within the brainstem, and are sensitive to the pH of their environment.

These chemoreceptors are highly responsive to carbon dioxide. The

normal level of PCO2 in the arterial blood is 40mmHg. An increase in

carbon dioxide concentration causes a drop to blood pH due to the

production of H+ ions from carbonic acid. In response to the drop in

blood pH, the neurons in the medullary inspiratory center begin to fire at an increased rate. The impulses that are sent down the spinal cord

and through the phrenic nerve stimulate the nerves in the diaphragm

and external intercostal muscles, triggering inspiration to remove carbon

dioxide from the blood through the lungs.

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Air typically moves from areas of high pressure to areas of low pressure. As

such, when the diaphragm moves downward and the intercostal muscles

move outward, pressure inside the chest is reduced, causing air to move

into the lungs. Eventually, the inspiratory center in the medulla stops firing these impulses and the expiratory center takes over and begins firing,causing expiration.

During hyperventilation, too much carbon dioxide is removed from the

blood to cause alkalosis. The chemoreceptors detect this change and send

a signal to the medulla to decrease ventilation so that carbon dioxide and

pH can return to normal levels.

There are also peripheral chemoreceptors in the aortic and carotid bodies,

(located beneath the angle of the jaw) which act principally to detect

changes in oxygen and carbon dioxide in arterial blood as well as blood

pH.

CO2+ H

2O = H

2CO

3 = H+ + HCO

3–

Carbon dioxide combines with water in the blood to form carbonic acid.

When this occurs, it disassociates into H+ (hydrogen ions) and HCO3-

(bicarbonate ions), creating an alkaline buffer that neutralises changes in

the blood’s acidity (reversibly binds H+).

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If the body removes a lot of carbon dioxide (through hyperventilation,

for example), it is left with an excess of bicarbonate ions and a deficiency

of hydrogen ions. Breathing volume significantly decreases during bouts

of short-term hyperventilation to facilitate the accumulation of carbon

dioxide and the normalization of the blood’s pH levels. However, if this

over-breathing continues for longer periods (hours to days), the kidneys will

begin to offload bicarbonate ions in an attempt to normalize the blood’s

pH levels. Hypocapnia and pH shifts happen almost immediately, but the

removal of bicarbonate ions can take longer. This was initially thought to

be hours to days, but in some instances it can occur within minutes (Lum,

1975).

Thus, for chronic hyperventilators, maintaining optimal pH levels is a

delicate balance. Diminished acid due to hyperventilation is carefully

balanced against the low levels of blood bicarbonate maintained by the

kidneys’ excretion. Even slight over-breathing due to stress or raised

emotions can result in a steep drop in carbon dioxide, thus causing

symptoms to worsen (King 1988).

Carbon dioxide is twenty-four times more soluble than oxygen in the

blood. There is little difference between CO2 in the alveoli of the lungs and

arterial blood. The pressure of carbon dioxide in arterial blood is entirely

dependent on alveolar CO2 levels, while alveolar CO2 is dependent on

breathing volume.

The functions of carbon dioxide include:

Primary regulator of blood pH

Catalyst for the release of oxygen from the blood into the cells

Dilator of smooth muscle (embedded in circulation and bronchioles of

lower airways)

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Primary regulator of blood pH

According to Rachel Cassiday and Regina Frey from the Department of

Chemistry, Washington University, St. Louis, MO; “ideally, the pH of the

blood should be maintained at 7.4. If the pH drops below 6.8 or rises

above 7.8, death may occur” (Casiday & Frey, 1988).

Function of carbon dioxide: catalyst for Hb to release oxygen into the

cells (Bohr Effect)

In 1904, Christian Bohr, a Danish biochemist, discovered that “the lower

the partial pressure of carbon dioxide (CO2) in arterial blood (PaCO

2), the

greater the affinity of hemoglobin for the oxygen it carries”. An increase in the concentration of carbon dioxide in the blood leads to a direct decrease

in the pH of the blood, causing the blood’s hemoglobin proteins to release

their oxygen load. This process was named the Bohr Effect. To put it more

simply, the lower the partial pressure of carbon dioxide in arterial blood,

the less oxygen released by hemoglobin into the cells for the production

of energy. When breathing through the nose during exercise, aCO2 levels

are higher, and the oxygen taken in is distributed more efficiently to the fatigued tissues.

Oxyhemoglobin dissociation curve (ODC)

Horizontal axis: PO2 : Partial pressure of O

2.

Vertical axis: SpO2 : Percentage of oxygenated hemoglobin versus

total hemoglobin in arterial blood (Hb allows seventy times more O2 to

be carried).

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An easy way to understand the ODC is that an exercising muscle is hot and

generates carbon dioxide, so it benefits from increased unloading of O2

from its capillaries (West, 1995).

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Function of carbon dioxide: constriction and dilation of carotid arteries

A 50 percent reduction in the oxygen available to the brain is a primary

response to hyperventilation (Timmons & Ley, 1994).

CO2 response to hyperventilation

Arterial carbon dioxide tension and alveolar carbon dioxide are virtually

identical, and arterial CO2 is directly proportional to alveolar CO

2. A

decrease in PaCO2 (arterial) can result from hyperventilation. A decrease

in PaCO2 without a change in the bicarbonate increases the blood pH,

thus producing respiratory alkalosis. The changes in the arterial CO2

content and tension are greatest during the first thirty to sixty seconds of acute hyperventilation. PaCO

2 can decrease to half the normal value

after less than thirty seconds of hyperventilation. One deep inspiration

and expiration can cause PaCO2 levels to drop by 7-16mmHg, and it is

accompanied by reduced oxygen delivery to the brain.

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However, in a randomized, double-blind study conducted by Hornsveld

et al., a fall in PCO2 was not required for the development of symptoms

in most of the subjects tested. It was revealed that the very act of over-

breathing to stimulate stress can trigger symptoms without any drop in

carbon dioxide. Alongside the “metabolic” pathway for the control of

breathing (via the respiratory center in the medulla), there is also the motor

or “behavioral” pathway. This pathway is presumed to cause the increased

need to take large breaths during strenuous exercise, even when PCO2

levels remain unchanged or are lower than when at rest (Hornsveld, 1996;

Howell, 1997).

Transcutaneous CO2

In sports and traumatology medicine, skeletal muscle injuries are among

the most common, often causing pain, physical dysfunction, decreased

performance and restricting the athlete from competing or returning to

training. Fortunately, early diagnosis and appropriate treatment can reduce

the impact of injury.

Skeletal muscle is essentially a composite of various myofibers bundled

together to form the mechanical system responsible for the movement of

the limbs. Some studies have suggested that transcutaneous application

This is caused by the Bohr Effect and the reduction in blood flow to the brain, resulting in a variety of symptoms, including the feelings of dizziness,

faintness, visual disturbances and impaired psychomotor behavior that are

often described by individuals experiencing hyperventilation (Brashear,

1983).

Carbon dioxide anomalies

There is a common acceptance that the hyperventilation provocation

test (HVPT), which consists of voluntarily over-breathing for one to three

minutes, creates certain symptoms by triggering hypocapnia (a drop in the

pressure of carbon dioxide in arterial blood).

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of CO2 could increase the number of mitochondria in the skeletal muscle,

leading to advantages such as increased muscle endurance and enhanced

repair and recovery.

In a study by Akahane et al. (2017), twenty-seven rats were used to

investigate whether transcutaneous application of carbon dioxide could

indeed accelerate muscle repair. After inflicting an injury to the tibialis

anterior muscle, a muscle that runs down the front of the shin in humans,

the rats were divided into two randomly assigned groups. One group was

treated with transcutaneous carbon dioxide, while the other remained

untreated. The results showed that, in the group treated with carbon

dioxide, the muscle injury was completely healed by the sixth week.

However, in the untreated group, only partial repair was observed in the

damaged muscle (Akahane et al., 2017).

Although it is well established that endurance exercise generates carbon

dioxide through the aerobic metabolic process, the entirety of its role is

not yet clear. However, it is known that exogenous CO2 by transcutaneous

delivery promotes the switching of muscle fibertypes, which is linked to

increased endurance and power in the skeletal muscles.

The study concluded that carbon dioxide promotes muscle fiber type switching from fast-twitch to slow-twitch, allowing the skeletal muscles

to endure for longer and recover quicker once fatigued, thus improving

overall physical performance in the group receiving transcutaneous carbon

dioxide.

An increase in the mitochondrial DNA content and capillary density was

also noted in the CO2 group, further confirming that carbon dioxide was

beneficial for performance and muscle development during endurance exercise, and also suggesting that it may enhance recovery from fatigue

and support anabolic metabolism in the skeletal muscles.

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As breath-holding is also known to cause acidosis in humans through

decreased pH and the loss of affinity for O2 (also known as the Bohr

Effect), which facilitates oxygen delivery to the tissues, it may be possible

that, as with transcutaneous CO2, breath-holding can potentially improve

performance and recovery of injured or fatigued skeletal muscles in

humans, too.

Co2 and injury – breath holding

The increased oxygen pressure in the tissues after carbon dioxide therapy

(i.e., the transcutaneous delivery of CO2) is based on the Bohr Effect.

A study by Sakai et al. (2011) investigated whether CO2 absorption and

the Bohr Effect could be induced in humans through transcutaneous

application of pure carbon dioxide.

It was noted that ten minutes after transcutaneous application of CO2,

the intracellular pH of the triceps surae, a pair of muscles located in the

calf, significantly decreased. Furthermore, NIRS data revealed that just

four minutes after CO2 application, there was a significant decrease in

the subject’s oxy-Hb concentration. Additionally, an increase in deoxy-

Hb concentration was observed just two minutes after the application of

CO2. Using NIRS data, the researchers confirmed that the transcutaneous

application of CO2 in humans facilitates the absorption of CO

2 and causes

oxygen dissociation from oxy-Hb, which is characteristic of the Bohr Effect,

thus proving the effect can be artificially induced in vivo. This discovery could potentially benefit those with disorders and injuries that can be treated with high levels of localized oxygen in the tissues to repair damage

and recover functionality (Sakai et al., 2011).

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Class 1 References

Akahane, S., Sakai, Y., Ueha, T., Nishimoto, H., Inoue, M., Niikura, T. and

Kuroda, R. (2017). Transcutaneous carbon dioxide application accelerates

muscle injury repair in rat models. International Orthopaedics, 41(5),

pp.1007-1015.

Bradley H, Esformes J. (2014). Breathing pattern disorders and functional

Movement. The International Journal of Sports Physical Therapy, (9)1.

Brashear, R. (1983). Hyperventilation syndrome. Lung, 161(1), pp.257-273.

Casiday R & Frey R,.Blood, Sweat and Buffers: pH Regulation During

Exercise. Department of Chemistry, Washington University, St. Louis, MO.

Chapman, E. et al.(2016) A clinical guide to the assessment and treatment

of breathing pattern disorders in the physically active: part 1. The

International Journal of Sports Physical Therapy, 11(5), pg.803.

Ferretti, G., Moia, C., Thomet, J. and Kayser, B. (1997). The decrease of maximal oxygen consumption during hypoxia in man: a mirror image of the

oxygen equilibrium curve. The Journal of Physiology, 498(1), pp.231-237.

Hornsveld, H., Garssen, B., Fiedeldij Dop, M. and van Spiegel, P. (1996).

21. Placebo-controlled validation of the hyperventilation-provocation test:

is there a hyperventilation syndrome?. Biological Psychology, 43(3), p.254.

Howell, J. (1997). The hyperventilation syndrome: a syndrome under threat?. Thorax, 52(Supplement 3), pp.S30-S34.

Huang, T. and Young, T. (2014). Novel Porous Oral Patches for Patients

with Mild Obstructive Sleep Apnea and Mouth Breathing. Otolaryngology–

Head and Neck Surgery, 152(2), pp.369-373.

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Ilyukhina, V. and Zabolotskikh, I. (2000). Physiological basis of differences

in the body tolerance to submaximal physical load to capacity in healthy

young individuals. Human Physiology, 26(3), pp.330-336.

Kiesel, K., Rhodes, T., Mueller, J., Waninger, A. and Butler, R. (2017). Development of a screening protocol to identify individuals with

dysfunctional breathing. International Journal of Sports Physical Therapy,

12(5), pp.774-786.

King, J. (1988). Hyperventilation-A Therapist’s Point of View: Discussion Paper. Journal of the Royal Society of Medicine, 81(9), pp.532-536.

Loeschcke, H., Koepchen, H. and Gertz, K. (1958). . Effect of hydrogen ion

concentration and carbon dioxide pressure in the cerebrospinal fluid on respiration. Pflugers Archiv Gesamte Physiology Menschen Tiere, 266(6),

pp.569-585.

Lum, L. (1975). Hyperventilation: The tip and the iceberg. Journal of

Psychosomatic Research, 19(5-6), pp.375-383.

Nishino, T. (2009). Pathophysiology of dyspnea evaluated by breath-

holding test: Studies of furosemide treatment. Respiratory Physiology &

Neurobiology, 167(1), pp.20-25.

Parkes, M. (2012). The Limits of Breath Holding. Scientific American,

306(4), pp.74-79.

Rassovsky, Y., Abrams, K. and Kushner, M. (2006). Suffocation and

respiratory responses to carbon dioxide and breath holding challenges in

individuals with panic disorder. Journal of Psychosomatic Research, 60(3),

pp.291-298.

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Sakai, Y., Miwa, M., Oe, K., Ueha, T., Koh, A., Niikura, T., Iwakura, T., Lee,

S., Tanaka, M. and Kurosaka, M. (2011). A Novel System for Transcutaneous

Application of Carbon Dioxide Causing an “Artificial Bohr Effect” in the

Human Body. PLoS ONE, 6(9), p.e24137.

Timmons B.H., Ley R. (1994) Behavioral and Psychological Approaches to

Breathing Disorders. (1st ed.) Springer.

Trembach, N. and Zabolotskikh, I. (2017). Breath-holding test in evaluation

of peripheral chemoreflex sensitivity in healthy subjects. Respiratory

Physiology & Neurobiology, 235, pp.79-82.

West, J. (2012). Respiratory physiology. Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkins.

Woorons, X., Mollard, P., Pichon, A., Lamberto, C., Duvallet, A. and

Richalet, J. (2006). Moderate exercise in hypoxia induces a greater arterial

desaturation in trained than untrained men. Scandinavian Journal of

Medicine and Science in Sports, pp.431-436.

Zubieta-Calleja, GR., Zubieta-Castillo, G., Paulev, PE., Zubieta-Calleja, L.,

(2005). Non-invasive measurement of circulation time using pulse oximetry

during breath holding in chronic hypoxia. Journal of Physiology and

Pharmacology. 56(4), pp.251-256.

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CHAPTER 2

INCREASING OXYGEN UPTAKE DURING REST AND PHYSICAL

EXERCISE

Tidal volume: the normal volume of air entering the lungs during one

inhale at rest.

Respiratory rate: the number of breaths per minute.

Minute ventilation: the volume of air that enters the lungs over one

minute.

RR * TV= MV

With each breath taken into the body, 150ml remains in the nasal cavity,

throat, trachea, bronchi and bronchioles. The remainder of the breath

reaches the small air sacs (alveoli), whose function is to allow gas exchange

to take place. Dead space air is useless in terms of gas exchange from the

lungs to the blood. By reducing the volume of air remaining in this dead

space during each minute of ventilation, breathing efficiency and gas exchanges improve for a given minute ventilation.

In the following two examples, the volume of air drawn into the nose

remains the same at six liters.

By reducing the respiratory rate from twelve breaths per minute to six

breaths per minute, the volume of air reaching the small sacs in the lungs

increases by circa 20 percent, from 4.2 liters to 5.1 liters. This represents

a 20 percent increase in breathing efficiency. If minute ventilation is normal, then 20% less air is required to achieve a same degree of alveolar

ventilation.

Example 1:

RR * TV= MV

Nose: 12 * 500 = 6 liters

Alveoli: 12* (500-150) = 4.2 liters

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Example 2:

RR * TV= MV

Nose: 6 * 1000 = 6 liters

Alveoli: 6 * (1000-150) = 5.1 liters

Slow breathing involves reducing the number of breaths per minute.

This enhances ventilation efficiency and arterial oxygenation as a greater volume of air reaches the small air sacs of the lungs, the alveoli, where gas

exchange takes place. By reducing the respiratory rate, proportionately

more air per breath reaches the alveoli and less air remains in the dead

space (Bilo et al., 2012). Breathing efficiency is important for sports, climbing altitude, and respiratory or cardio disorders.

Exercises designed to permanently slow the rate of breathing can reduce

dyspnoea and improve performance during strenuous exercise (Bernardi,

Spadacini, Bellwan, Hajiric & Raskamm, 1998).

Breathing at high-altitude

The air becomes thinner at high altitudes as the atmospheric pressure

reduces. During a climb or hike at high altitude, the PO2 in alveolar air

and in arterial blood lowers. During an ascent and while at high altitude,

oxygen uptake in the lungs and blood can be increased by changing the

respiratory rate.

Slow breathing improves arterial oxygenation by increasing alveolar

volume and gas exchange at the level of the alveolar-capillary membrane

(Biloet al., 2012). Breathing fewer breaths per minute than usual (slow

breathing) and using the diaphragm breathing muscles (deep breathing)

improves blood oxygenation in subjects chronically exposed to high

altitude (Keyl et al., 2003).

To investigate the effects of slow breathing at high altitude on oxygen

saturation, thirty male and nine female subjects aged twenty-four to sixty-

one years were recruited. At sea-level, all subjects’ SpO2 was between 95

percent and 100 percent.

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Changing the breathing pattern from spontaneous to a paced frequency

of six breaths per minute improved efficiency of breathing by significantly increasing blood oxygen saturation. Blood oxygen saturation at high

altitude increased from severe hypoxia of 80.2 percent to mild hypoxia of

89.5 percent in Study A and from 81.0 percent to 88.6 percent in Study B.

The increase in blood oxygen saturation occurred quickly and was

maintained during the slow breathing period. Most of the improvement

in blood oxygenation was lost within five minutes after the restoration of the subjects’ usual breathing pattern. All improvements were lost thirty

minutes after returning to usual breathing patterns (Bilo et al., 2012).

It is normal for breath-hold time to decrease as one ascends to high

altitude, and breath-holding time has been used to evaluate high-altitude

adaptation among mountain climbers (Zubieta-Calleja et al., 2005).

NOSE BREATHING

In addition to providing a sense of smell, the nose also performs the

important function of filtering and preparing air before it enters the lungs. As the nostrils are significantly smaller than the mouth, breathing through the nose creates approximately 50 percent more resistance compared

to mouth breathing during wakefulness, resulting in a 10 to 20 percent

greater oxygen uptake in the blood.

Healthy nasal breathing is vital. It allows the body to utilize nitric oxide and

carbon dioxide in the blood to expand the blood vessels. In 1904, Danish

biochemist Christian Bohr demonstrated the importance of carbon dioxide

in blood oxygenation. However, it was not until the 1980s that the many

benefits of nitric oxide (NO) were fully understood. In the intervening years, many considered nitric oxide a toxic gas, associating it with environmental

pollution and the dirty smog often experienced in overpopulated cities. In

the mid-1990s, scientists discovered that nitric oxide was being produced

in the paranasal sinuses—a group of four air-filled spaces surrounding the nasal cavity. Thus, as we take a breath in through the nose, a large quantity

of nitric oxide is released in the nasal airways (Lundberg & Weitzberg, 1999).

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According to Jon Lundberg, professor of Nitric Oxide Pharmacologics at

the world-famous Karolinska Institute in Sweden, large amounts of nitric

oxide are constantly being released in our nasal airways as we breathe. As

a breath is taken in through the nose, nitric oxide will follow that airflow

down into the lungs for the purpose of increasing the amount of oxygen

uptake in the blood.

The nitric oxide then follows the airflow to the lungs, where it serves a

number of very important roles, including the opening of the airways and

increasing oxygen uptake in the blood (Lundberg, 2008).

Ventilation perfusion describes the ratio of air to blood that reaches the

alveoli each minute. Ideally, the oxygen gained by breathing would be

enough to fully saturate the blood. There are two factors that negatively

impact ventilation perfusion: mouth breathing and gravity. Both of

these factors can cause the higher parts of the lungs to receive greater

ventilation and the lower parts to receive greater amounts of blood.

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The nitric oxide that is produced in the nasal cavity facilitates a significantly more efficient balance of blood flow to ventilation. Nitric oxide is carried into the lungs after a breath is taken through the nose to help redistribute

the blood more equally, thus counteracting the negative effect of gravity

on blood flow in the lungs (Sanchez Crespo, Hallberg, Lundberg, Lindhal, Jacobsson, Weitzberg & Nyren, 2010).

Contrary to the advice of many sports coaches to breathe “in through the

nose and out through the mouth”, it is actually far more advantageous to

breathe in and out through the nose. This approach not only facilitates

better body oxygenation, but it also helps prevent a blocked nose and

supports easier breathing during exercise and rest. Studies have shown

that exhaling through the mouth can result in the loss of heat and up to 42

percent more water than exhaling through the nose (Svensson et al., 2006).

The increase in heat and water loss through mouth breathing can result

in symptoms of nasal obstruction (blocked nose) and difficulty breathing. The blocked nose encourages the individual to continue breathing through

the mouth, thus perpetuating the condition. However, in this instance,

the counter-intuitive act of breathing through the nose can actually help

to keep the airways clear, prevent dehydration, and improve the person’s

healthy breathing volume. Practicing breath-holding techniques not only

improves body oxygenation, but it can also be used to easily decongest

the nose.

Slow breathing

Nasal breathing: more likely to breathe deeper into the lungs.

Nasal nitric oxide: redistributes blood throughout the lungs.

Improves ventilation perfusion to improve oxygen uptake in the blood.

When total nasal obstruction is present, total lung capacity, functional

residual capacity and residual volume all decreased significantly. This implies that the resistance to expiration created by the nose

helps maintain lung volumes and could indirectly determine arterial

oxygenation (Swift, Campbell, McKown,1988).

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NASAL BREATHING DURING PHYSICAL EXERCISEEarlier on, we read that carbon dioxide is the primary stimulus to breathe. Nose breathing during physical exercise slows down the speed of breathing and reduces breathing volume, causing an increase in carbon dioxide in the blood. Few individuals spontaneously choose to breathe through their nose during heavy exercise (Saibene et al., 1978). If one has not trained for at least six to eight weeks with nasal breathing during physical exercise, the air hunger can be quite strong at some levels of intensity, causing a switch to mouth breathing.

Breathing through the nose is comfortable at lower levels of intensity, where minute ventilation is less than 35 liters. When minute ventilation is 35 to 41 liters, the switch to mouth breathing is made (Ninnima et al., 1980). Multiple studies have failed to identify the exact switching point from nose to mouth breathing, as this will be influenced by the sensitivity of the individual to carbon dioxide build-up, metabolism, and the size of the individual’s nose. A spacious nasal cavity and large nostrils are advantageous for nasal breathing during physical exercise. Due to a larger opening, breathing through the mouth imposes less resistance to breathing. Breathing through the mouth is faster and allows a greater volume of air to enter the lungs. This reduces carbon dioxide in the blood, leading to a reduction to air hunger (Dallam et al., 2018).

A study by Dallam et al. (2018) consisted of five male and five female recreational athletes who breathed only through their nose during all training and racing for a minimum of six months before the study.

At six months, when adaptations had taken place, the subjects were tested

while breathing through the nose and while breathing through the mouth.

The results were as follows:Respiratory rate 39.2 (nasal) 49.4 (oral)Increased EtCO

2 mmHg 44.7 (nasal) 40.2 (oral)

Same peak work and maximal oxygen consumption in a GXT while breathing nasally compared to breathing orally.Significantly reduced RR and ventilation (VE) at VO

2 max during nasal

breathing. (On average, VE was reduced by 22%.)Decreased PETO

2 and FEO

2 in their expired air at VO

2 max (Nasal

breathing)Increased PETCO

2 and FECO

2 (Nasal breathing)

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At six months, all participants were able to achieve the same peak work

and maximal oxygen consumption in a GXT while breathing nasally that

they achieved while breathing orally. A GXT is a graded exercise test to

track an individual’s fitness level by measuring cardiovascular response to physical activity. They were able to achieve adequate oxygenation to work

rates that were as high as in oral breathing, probably due to the slower

breathing pattern allowing increased time for diffusion of oxygen from

the lungs into the blood. As ventilation is produced by muscular work,

a 22 percent reduction in ventilation logically reflects a reduced work of breathing, which is likely to be more economical. In other words, less

energy is wasted on supporting the breathing muscles. The study showed

a lower VO2, which the authors suggest might be due to less metabolic

energy production being required to produce the same result. This is more

physiologically economical as a result. Nasally restricted breathing during

exercise might be viewed as a potential way to improve performance in

endurance events where economy is a critical performance factor (Joyner & Coyle, 2008). The experience of air hunger can be diminished greatly

through repeated exposure to higher carbon dioxide in the blood through

nasal breathing. (Bloch-Salisbury et al., 1996; Dallam et al., 2018).

NASAL BREATHING WORKLOAD DURING PHYSICAL EXERCISE

During exercise, nasal breathing causes a reduction in FEO2 (the fraction of

expired air that is oxygen (O2 percentage)), indicating that, on expiration,

the percentage of oxygen extracted from the air by the lungs is increased

(Morton, 1995).

The exercise intensity that could be achieved by healthy subjects while

nasal breathing was 90 percent of their max workload (at least for the short

period during the test) (Thomas et al., 2009). In the same article by Thomas

et al. (2009), twelve healthy physiotherapy students aged between twenty-

one and twenty-seven years (eight male and four female) completed both

runs. Nasal breathing was continued to 85 percent of VO2 peak, indicating

that people are capable of nose breathing at much higher intensities than

they would normally choose to do.

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Air hunger during exercise

The air hunger experienced while breathing through the nose during

physical exercise will be impacted by a small nose or narrow nostrils. If the

nasal airway is small, the resistance to breathing may be too much during

physical exercise, resulting in an extreme feeling of air hunger. In order to

help open the nasal passages, a nasal dilator could be used. One brand

specific to physical exercise is called the Turbine Nasal Dilator.

In addition, it is much easier to maintain nasal breathing during exercise

if you breathe efficiently. Continued nasal breathing over a period of six to eight weeks will cause adaptations to the body, resulting in improved

breathing efficiency and a reduced feeling of air hunger.

To reduce the feeling of air hunger during physical exercise, work to

achieve a higher BOLT score and breathe light, slow and deep.

Light: only breathe a volume of air that you need (do not over-breathe).

Slow: reduce your respiratory rate.

Deep: breathe using the diaphragm.

Recreational athletes

As stated in Dallam’s paper (2018), healthy individuals can breathe entirely

nasally at the lower levels of work necessary to improve aerobic fitness without any specific adaptation to the process. Therefore, it is advised that recreational athletes maintain nasal breathing at all times. If the air hunger

is so strong that the recreational athlete needs to open their mouth, they

should simply slow down and allow their breathing to calm once more.

Competitive athletes

It is probably best for competitive athletes to alternate nasal breathing

with mouth breathing. High-intensity training helps to prevent muscle

deconditioning and will require an athlete to periodically breathe through

their mouth. For less-than-maximum intensity training, and at all other

times, nasal breathing should be employed.

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For example, a competitive athlete may spend 50 percent of their

training with their mouth closed.

Use mouth breathing when working at an all-out pace in order to

maintain muscle condition.

During competition, there is no need to intentionally take bigger

breaths. Instead, achieve a higher BOLT score and apply the OA pre-

competition preparation (further on).

Nasal breathing with reduced volume breathing during the warm-

up can be very advantageous, as can practicing light, slow and deep

breathing during the warm-down.

EXERCISE-INDUCED ASTHMA

Exercise-induced asthma (EIA) affects an estimated four to twenty percent

of the general population and eleven to fifty percent of certain athlete populations (Rundell, Mayers, Wilber, Szmedra & Schmitz, 2001). During a

routine screening of UK Olympic teams before the Athens Olympics, the

recorded prevalence of asthma was 21 percent (double the prevalence

rate of the UK population). The two sports with the highest prevalence of

asthma were swimming and cycling (both over 40 percent).

Breathing a larger volume of unconditioned air into the lungs pulls

moisture from the inner walls of the airways. This causes them to narrow

and constrict. Drying and cooling of the airways can contribute to

inflammation of the lungs (McConnell, 2011), creating feeling of tightness in the chest, breathlessness, wheezing or coughing.

Breathing through the nose increases the respiratory system’s ability to

warm and humidify the air that is taken in compared to oral breathing.

It also reduces the drying and cooling that occurs due to increased

ventilation during exercise. Having a higher BOLT score also results in

less air being drawn into the lungs, which in turn will reduce the onset

of dehydration. This will also reduce the severity of asthma caused by

exercising at a given intensity or duration (Morton, 1995).

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Individuals with asthma are also more likely to breathe through their

mouths, a factor that may contribute to the pathogenesis of their asthma

(Kairaitis, Garlick, Wheatley & Amis, 1999). Nasal breathing acts as a

protective barrier against exercise-induced asthma. In a study by Hallani

et al. (2008), it was found that mouth breathing caused a decrease in

lung function among individuals with mild asthma and even brought

on asthma symptoms in some. Mouth breathing is common among

individuals with asthma. There are a number of reasons for this, including

nasal congestion, a breathing pattern involving upper chest breathing,

and a quick respiratory rate. When persons breathed only through

the nose during exercise, there was an almost complete inhibition of

asthma symptoms post-exercise. When the subjects were instructed

to breathe only through the mouth during exercise, narrowing of the

airways occurred (Shturman-Ellstein, Zeballos, Buckley & Souhrada, 1978).

ADDRESSING EXERCISE-INDUCED BRONCHOCONSTRICTION (EIB)

It is essential that individuals prone to exercise-induced

bronchoconstriction (EIB) warm up with light intensity movement for a

minimum of ten minutes prior to physical exercise. During the warm up,

breathe only through the nose and reduce breathing volume in order to

create air hunger. The movement is not restricted to walking or jogging.

It makes sense to open the airways and blood vessels, harness nasal

nitric oxide and to increase oxygen delivery to the cells prior to physical

exercise. It is vital to increase the everyday BOLT score to above twenty-

five seconds. Any individual with a genetic predisposition to EIB is likely

to experience symptoms like chest tightness, coughing, wheezing, and

excessive breathlessness as long as their BOLT score remains less than

twenty-five seconds.

https://www.ncbi.nlm.nih.gov/pubmed/?term=Shturman-Ellstein%2520R%255bAuthor%255d&cauthor=true&cauthor_uid=677559

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IMPROVING SLEEP QUALITY FOR FOCUS AND PERFORMANCE

Light and calm breathing through the nose reduces both snoring and

obstructive sleep apnea, as well as activates the body’s relaxation mode,

leading to a deeper and better quality of sleep. Fifteen years ago, few

people were talking about sleep quality. Now, it is a hot topic with sleep

clinics available throughout the Western world. Breathing patterns strongly

influence sleep disorders. With a low BOLT score, breathing is likely to be

fast and shallow. This in turn will create turbulence in the upper airway,

resulting in snoring, upper airways resistance syndrome, hypopnea or

sleep apnea. Sleep has become the new frontier in improving sports

performance, with increasing numbers of elite athletes turning to expert

sleep coaches like Nick Littlehales for guidance. Waking up feeling groggy

and tired on the day of a competitive event is not the ideal recipe for

success. Alertness, energy and focus, on the other hand, are all essential

ingredients of a winning strategy.

Unfortunately, poor breathing habits go hand in hand with poor sleeping

habits, which in turn can have a detrimental effect on sports performance.

If there is any restriction to breathing during sleep, it may present as

a sleeping disorder, such as snoring or obstructive sleep apnea, which

will reduce the quality of your rest. This section provides a number of

recommendations guaranteed to help improve sleep and foster good

breathing habits both day and night.

Snoring

The noisy sound associated with snoring is created by turbulent airflow. It

is the result of the movement of a large volume of air through a narrowed

space while sleeping. This turbulent movement of air causes the tissues

within the nose and throat to vibrate. There are two factors at play here: 1)

the snorer is breathing heavily and noisily in their sleep, and 2) the snorer

may have a narrow upper airway due to nasal congestion or structural

issues.

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Snoring is generally classified into two different types; mouth snoring,

which involves vibration of the soft palate as air is drawn into the mouth,

and nose snoring, which consists of turbulent airflow inside the nasal cavity

and throat. It is very easy to address mouth snoring by simply taping the

mouth closed during sleep. There are a number of tapes available on the

market, including our own MyoTape and another tape by Dr. Frank Seaman

called LipSeal Tape. Research highlights that persons over forty years of

age are six times more likely than younger people to spend more than

50 percent of their sleep time breathing through their mouth and nose

combined. Anyone waking up with a dry mouth in the morning is unlikely

to feel refreshed. Improving your BOLT score and wearing tape across your

lips are effective ways of helping sleep-disordered breathing.

Sleep apnea

The term “Apnea” is a Greek word meaning “without breath”. There are

three main forms of apnea that occur during sleep: central, obstructive,

and a mixed apnea, which is a combination of the two. Sleep apnea

is considered to be a severe form of sleep-disordered breathing that

involves the sleeper involuntary stopping their breathing during sleep.

After a period of time spent not breathing, the sleeper partially awakens to

resume breathing with large gasps.

Central sleep apnea

When the brain fails to send the body the correct signal to breathe, this

is called central sleep apnea. If the sleeping person stops breathing,

the breathing muscles do not automatically intervene to help restart

breathing. In most cases, the brain will eventually send the right signal to

the body and breathing will resume. Central sleep apnea is a relatively

rare condition. However, some patients who have been diagnosed with

obstructive sleep apnea can also have occasional occurrences of central

sleep apnea, too.

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Obstructive sleep apnea (OSA)

Obstructive sleep apnea is the most common type of apnea. It is

characterized by the stopping of breathing due to the collapse of the

throat during sleep. Originally described as Pickwickian syndrome, this

type of breathing was later categorized as obstructive sleep apnea

syndrome by the late Dr. Christian Guilleminault. In the early 1970s, while

working at the Stanford University Sleep Disorders Clinic, Dr. Guilleminault

teamed up with cardiologists to monitor the blood pressure of sleeping

patients. The team discovered that when patients stopped breathing

during sleep, their blood pressure dramatically increased. When this

continued over time, the increase in blood pressure became permanent,

occurring both day and night.

Needless to say, obstructive sleep apnea exerts considerable stress on the

body, often resulting in poor health. People with obstructive sleep apnea

experience decreased quality of life and functional capacity, alongside

a markedly increased risk of cardiovascular disease and death. There is

growing data that OSA is also associated with an increased risk of diabetes

and cancer, and it constitutes a major treatable risk factor for hypertension,

coronary artery disease (CAD) and stroke.

Stopping of the breath can occur five to fifty times per hour, and the duration of the breath-hold can range from a few seconds to over one

minute, causing one’s blood oxygen saturation to decline to as low as

50 percent. While sleep disorders can affect athletes across all sports

and disciplines, well-built males with a neck circumference of more than

seventeen inches are at greater risk. In general, a large neck circumference

coincides with a narrower upper airway, causing breathing to stop

during sleep. In one study of professional American football players, the

prevalence of sleep-disordered breathing was found to be 14 percent

overall and 34 percent within the high-risk group, which included the larger

offensive and defensive linemen (George, Kab & Levy, 2003).

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According to Dr. Christopher Winter, M.D., medical director of the Martha

Jefferson Hospital Sleep Medicine Center in Charlottesville, Virginia:“There are athletes everywhere who have sleep apnea. Not only does the

apnea affect their athletic performance, but it is extremely hard on their

cardiovascular systems as well.”

Though heart-related deaths from untreated sleep apnea usually occur

during sleep, chronic stress on the heart can leave victims vulnerable

during strenuous athletic events. An athlete who is pushing their heart

through sporting activity during the day and through apnea during their

sleep is not allowing their heart to rest and recover.

People who suffer from asthma experience a far higher incidence of

obstructive sleep apnea than their non-asthma-suffering counterparts,

and many research papers have concluded that as the severity of asthma

increases, so does obstructive sleep apnea. For example, one paper

demonstrates that approximately 74 percent of people with asthma also

experience nocturnal symptoms of airflow obstruction (Bonekat & Hardin, 2003). In another study, it has been found that obstructive sleep apnea-

hypopnea is significantly more prevalent among patients with severe asthma compared to those with moderate asthma, and it is more prevalent

for both asthma groups than control groups without asthma (Julien et al., 2009). Given the relationship between asthma and OSA, it is sensible to

assume that treating one disorder will result in better control of the other

and vice versa (Razak & Chirakalwasan, 2016).

It is well documented that breathing through your mouth during the

night leads to poorer quality sleep (George et al., 2003). In an interesting

study that aimed to determine the effect of a blocked nose during sleep,

subjects slept with their nostrils blocked on one night and open on

another. Blocking the nose caused participants to wake up more often,

reduced the quality of their sleep, and caused a significant increase in sleep disorders (Olsen, Kern & Westbrook, 1981).

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In another study to determine the effect of breathing through the nose

during sleep by wearing a porous paper tape across the lips, researchers

found that the number of sleep disturbances was significantly reduced. Thirty patients with mild sleep apnea, having between five and fifteen events hourly on the apnea-hypopnea index (AHI), were enrolled (Huang

et al., 2014). All patients slept with their mouths closed by using a porous

tape across their lips.

Before TAPE Using TAPE

ESS 8.1 ± 1.5 5.2 ± 1.6

VAS 7.5 ± 2.0 2.4 ± 1.4

ESS is the Epworth sleepiness scale

VAS is the visual analog scale

The median AHI score was significantly decreased from 12 events per

hour before treatment to 7.8 per hour during treatment (P < .01) by using

the porous tape (i.e., the median AHI was reduced by 33 percent just by

closing mouth!) (Huang et al., 2014).

Getting a better night’s sleep

A low BOLT score and mouth breathing contribute to the following:

Snoring, sleep apnea

Disrupted sleep

Nightmares

Asthma symptoms (3am to 5am)

Needing to use the bathroom during the night

Fatigue first thing in the morning

Dry mouth upon waking

Symptoms upon waking, including a blocked nose, wheezing,

coughing or breathlessness

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Improve sleep through the following:

Switch to nasal breathing permanently (tape mouth to ensure)

Avoid blue light for at least two hours before sleep-no smart phone or

laptop!

Sleep in a cool and airy bedroom

Don’t eat late at night or drink alcohol

Practice breathing softly for twenty minutes before sleep –

parasympathetic nervous system

Sleep on your side or tummy (not on the back)

Use a nasal dilator (MuteSnoring)

Tape the mouth closed using MyoTape or LipSealTape

Provide each student with tape

Demonstrate how to apply it

Wear the tape for twenty minutes during the day to become

comfortable with it

If the mouth is naturally moist in the morning, there is no need for tape

Class 2 References

Bernardi, L., Spadacini, G., Bellwon, J., Hajric, R., Roskamm, H. and Frey, A. (1998). Effect of breathing rate on oxygen saturation and exercise

performance in chronic heart failure. The Lancet, 351(9112), pp.1308-1311.

Bilo, G., Revera, M., Bussotti, M., Bonacina, D., Styczkiewicz, K., Caldara,

G., Giglio, A., Faini, A., Giuliano, A., Lombardi, C., Kawecka-Jaszcz, K., Mancia, G., Agostoni, P. and Parati, G. (2012). Effects of Slow Deep

Breathing at High Altitude on Oxygen Saturation, Pulmonary and Systemic

Hemodynamics. PLoS ONE, 7(11), p.e49074.

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Bloch-Salisbury, E., Shea, S., Brown, R., Evans, K. and Banzett, R. (1996). Air

hunger induced by acute increase in PCO2 adapts to chronic elevation of

PCO2 in ventilated humans. Journal of Applied Physiology, 81(2), pp.949-

956.

Bonekat, H. and Hardin, K. (2003). Severe Upper Airway Obstruction

During Sleep. Clinical Reviews in Allergy & Immunology, 25(2), pp.191-

210.

Campbell, I. and Swift, A. (1988). Oronasal obstruction, lung volumes, and

arterial oxygenation. The Lancet, 331(8600), pp.1458-1459.

George, C., Kab, V. and Levy, A. (2003). Increased Prevalence of Sleep-

Disordered Breathing among Professional Football Players. New England Journal of Medicine, 348(4), pp.367-368.

Hallani, M., Wheatley, J. and Amis, T. (2008). Enforced mouth breathing decreases lung function in mild asthmatics. Respirology, 13(4), pp.553-558.

Huang, T. and Young, T. (2014). Novel Porous Oral Patches for Patients

with Mild Obstructive Sleep Apnea and Mouth Breathing. Otolaryngology–

Head and Neck Surgery, 152(2), pp.369-373.

Joyner, M. and Coyle, E. (2008). Endurance exercise performance: the physiology of champions. The Journal of Physiology, 586(1), pp.35-44.

Julien, J., Martin, J., Ernst, P., Olivenstein, R., Hamid, Q., Lemière, C., Pepe, C., Naor, N., Olha, A. and Kimoff, R. (2009). Prevalence

of obstructive sleep apnea–hypopnea in severe versus moderate

asthma. Journal of Allergy and Clinical Immunology, 124(2), pp.371-376.

Kairaitis, K., Garlick, S., Wheatley, J. and Amis, T. (1999). Route of Breathing in Patients With Asthma. Chest, 116(6), pp.1646-1652.

Keyl, C., Schneider, A., Gamboa, A., Spicuzza, L., Casiraghi, N., Mori,

A., Ramirez, R., León-Velarde, F. and Bernardi, L. (2003). Autonomic

cardiovascular function in high- altitude Andean natives with chronic

mountain sickness. Journal of Applied Physiology, 94(1), pp.213-219.

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Lundberg, J. (2008). Nitric Oxide and the Paranasal Sinuses. The

Anatomical Record: Advances in Integrative Anatomy and Evolutionary Biology, 291(11), pp.1479-1484.

Lundberg, J. and Weitzberg, E. (1999). Nasal nitric oxide in man. Thorax,

54(10), pp.947-952.

M. Dallam, G., R. McClaran, S., G. Cox, D. and P. Foust, C. (2018). Effect

of Nasal Versus Oral Breathing on VO2 max and Physiological Economy in

Recreational Runners Following an Extended Period Spent Using Nasally

Restricted Breathing. International Journal of Kinesiology and Sports

Science, 6(2), p.22.

McConnell, A. (2011). Breathe strong, perform better. Champaign, IL:

Human Kinetics.

Morton, King, Papalia (1995) Australian Journal of Science and Medicine in Sport. 27, 51-55.

Niinimaa, V., Cole, P., Mintz, S. and Shephard, R. (1980). The switching

point from nasal to oronasal breathing. Respiration Physiology, 42(1),

pp.61-71.

Olsen, K., Kern, E. and Westbrook, P. (1981). Sleep and Breathing

Disturbance Secondary to Nasal Obstruction. Otolaryngology–Head and

Neck Surgery, 89(5), pp.804-810.

Razak, A., Chirakalwasan., N. (2016) Obstructive sleep apnea and asthma.

Asian Pac J Allergy Immunol. 34(4). pp.265-271.

Rundell, K., Im, J., Mayers, L., Wilber, R., Szmedra, L. and Schmitz, H. (2001). Self-reported symptoms and exercise-induced asthma in the elite

athlete. Medicine and Science in Sports and Exercise, pp.208-213.

Saibene, F., Mognoni, P., Lafortuna, C. and Mostardi, R. (1978). Oronasal

breathing during exercise. Pflügers Archiv European Journal of Physiology,

378(1), pp.65-69.

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Sánchez Crespo, A., Hallberg, J., Lundberg, J., Lindahl, S., Jacobsson, H., Weitzberg, E. and Nyrén, S. (2010). Nasal nitric oxide and regulation of

human pulmonary blood flow in the upright position. Journal of Applied

Physiology, 108(1), pp.181-188.

Shturman-Ellstein, R., Zeballos, R., Buckley, J., Souhrada, J. (1978) The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. American Review of Respiratory Disease, 118(1),

pp.65-73.

Thomas, S. A., Phillips, V., Mock, C., Lock, M., Cox, G. and Baxter, J. (2009) The effects of nasal breathing on exercise tolerance. In: Chartered Society

of Physiotherapy Annual Congress.

Zubieta-Calleja, GR., Zubieta-Castillo, G., Paulev, PE., Zubieta-Calleja,

L., (2005). Non- invasive measurement of circulation time using pulse

oximetry during breath holding in chronic hypoxia. Journal of Physiology

and Pharmacology. 56(4), pp.251-256.

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CHAPTER 3

BOLT (COMFORTABLE BREATH-HOLD TIME) MEASUREMENT



Hold your nose with your fingers to prevent air from entering yourlungs

Count the number of seconds until you feel the first distinct desire tobreathe in

How to measure breathlessnessIn 1975, Stanley et al. concluded that “the breath-hold time/partial pressure of carbon dioxide relationship provides a useful index of respiratory chemosensitivity”. By holding the breath, carbon dioxide accumulates in the blood as it is not able to leave the body through the lungs. The length of time that it takes for the brain to react to the accumulation of carbon dioxide provides an indirect index of the sensitivity of the body to CO

2 build-up. As carbon dioxide is the primary stimulus to

breathe, breath-holding is a powerful method to induce the sensation of breathlessness, and the breath-hold test “gives us much information on the onset and endurance of dyspnea.”(Nishino, 2009).

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In his book on exercise physiology, author William McArdle writes: “If a

person breath-holds after a normal exhalation, it takes approximately

40 seconds before the urge to breathe increases enough to initiate

inspiration”(McArdle, Katch & Katch, 2009). Many athletes attending our

training do achieve a BOLT score of forty seconds, but very few individuals

display a BOLT score of forty seconds on their first day of training. The normal score to expect from an athlete is approximately twenty seconds.

Individuals with a tendency toward asthma, childhood asthma, rhinitis, or

anxiety and panic disorders often achieve a BOLT score of between ten

and fifteen seconds.

HEART RATE VARIABILITY

A weight of evidence exists to support heart rate variability biofeedback

(HRVB) for a variety of common disorders and to improve performance

(Lehrer & Gevirtz, 2014). People with higher variability of heart rate are

healthier and more resilient, both physically and emotionally. Conversely,

persons who are emotionally sick, older or less aerobically fit have low HRV (Lehrer & Gevirtz, 2014).

Heart rate variability refers to the random and rhythmical variations to the

time between heartbeats. The time between each heartbeat is known as

the R–R interval, which is a physiological occurrence known as heart rate

variability (HRV).

The variability of the heart rate in synchronicity with respiration is known

as respiratory sinus arrhythmia (RSA). During inspiration, the heart rate

increases, and during expiration, the heart rate decreases (Russo, Santarelli

& O’Roarke, 2017).

Respiratory sinus arrhythmia controls the rate of gas exchange in the

alveoli. The heart rate is higher when the air in the lungs is rich with

oxygen, and exhalation occurs when carbon dioxide in the lungs is highest.

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RSA is controlled entirely by the vagus nerve, and it reflects aspects of autonomic functioning (Lehrer & Gevirtz, 2014). It is used as an index

of parasympathetic tone (Porges, 1986; Lehrer et al., 2000). Greater

traffic from the vagus nerve produces greater amplitudes of RSA. The vagal system interacts with the inflammatory system, and increases in vagus nerve traffic are associated with decreases in various inflammatory cytokines.

Slowing down breathing to a rate of six breaths per minute while increasing

tidal volume and diaphragmatic breathing has been shown to significantly increase RSA.

The major blood vessels contain pressure receptors that detect the

stretching of the arteries as blood pressure increases. When blood pressure

increases, the baroreflex causes immediate dilation of the blood vessels and a decrease in the heart rate. As blood pressure falls, the baroreflex causes immediate constriction of the blood vessels and increases the

heart rate (Lehrer et al., 2014). Both HRV (RSA) and baroreflex sensitivity are maximized when the breathing rate is slowed to about six breaths per

minute (Russo et al., 2017).

The BOLT score measures breath-hold time following an exhalation until

the first involuntary contractions of the breathing muscles. It provides feedback on the sensitivity of the body to the accumulation of carbon

dioxide. An inverse relationship exists between the sensitivity of the

baroreceptors and the sensitivity of the body to carbon dioxide build-up

(Trembach & Zabalotskikh, 2017). A strong sensitivity of the baroreceptors

exists with a reduced sensitivity to carbon dioxide. A high BOLT score

indicates reduced chemosensitivity to carbon dioxide.

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GET IN THE ZONE

During a high-stakes competition, it’s normal to feel the effects of

anxiety and adrenaline: your heart beats faster, butterflies flutter in your

stomach, and your palms get sweaty. And although an adrenaline boost

may sometimes help you to perform to the best of your abilities, anxious

symptoms are not so helpful. If you find your head flooded with thoughts

of past mistakes or ‘what ifs’ and are unable to keep your attention fully

focused on your game, your performance will suffer.

Maintaining control of the mind and staying focused are absolutely

critical in sports success. It can mean the difference between winning and

losing. Researchers at Coventry University tested the anticipation and

coordination abilities of eighteen active and healthy young adults during

two sets of identical physical tests: one set up as a practice, the other as a

competition. Interestingly, the study showed that the participants’ ability

to coordinate actions, such as catching a ball or striking a moving object,

were significantly worse during the competitive scenario. In addition, the

participants’ anxiety levels were found to be substantially higher during the

competitive trials and likely to be related to worries about performance.

The lead author of the study, Dr. Michael Duncan, commented that

“heightened cognitive anxiety, brought on by the competitive scenario,

really does affect performance abilities in physically active people—and

the same is likely to apply even for trained athletes.”

To excel in sports, it is just as important to devote attention to achieving

an optimal state of mind as it is to developing fitness, speed and strength.

The ability to be alert and maintain concentration is crucial. As the great

Finnish runner Paavo Nurmi said: “Mind is everything. Muscles = pieces of

rubber.”

Many athletes practice visualization, goal-setting and positive self-talk to

improve their mental state. However, some theorists believe that such

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practices may adversely affect sports performance as they distract the

athlete even further.

The terms “in the zone” or “in the flow” are commonly used in sports to describe the ideal mental state for optimal sports performance. Being in

the zone is a state of mind where complete attention is focused on the

task at hand. An athlete in the zone will perform to the best of their ability,

as mind, body and action become one. When you are in the zone, there

are very few distracting or negative thoughts, and your attention moves

simultaneously with time. In this state, concentration is not forced. Instead,

the mind is effortlessly immersed in what is taking place at that moment.

Concentration is the ability to hold one’s attention on an activity, task

or event without distraction. To excel in any activity, concentration is

vital. However, if the mind is easily distracted, then focus wavers and

performance suffers.

Nowadays, with the widespread use of smart phones, social media, email

and text messages, the mind is in an almost constant state of distraction

throughout the day. More and more, I notice my younger students

unconsciously and repeatedly taking their phones out of their pockets to

check for updates—an automatic and conditioned response similar to that

of an addict. While internet technology has brought many improvements

to modern life, it has also negatively impacted our concentration by

creating so many distractions.

If the mind is calm and in a state of concentration as you go about your

normal routine, this should translate into optimum mental performance

during competition. On the other hand, if the mind is all over the place

during day-to-day activities and you find it difficult to stay focused, then your concentration is unlikely to be at its best during sports.

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To determine how active your mind is, simply take a moment, relax, and

try to stop “actively” thinking. Then see how long it takes for a thought

to enter your mind. If this exercise is difficult and your mind is constantly

bombarded with thoughts, no matter how relaxed you are, then it’s likely

your concentration span is short as thought activity interferes with your

capacity to focus. But just as advancements in technology have trained

our minds to be distracted, it is also possible to re-train the brain to

concentrate with focused attention.

Since time immemorial, mankind has practiced focusing on the breath to

tame and train the brain. By observing the breath as it enters and leaves

the body, the brain is forced to focus exclusively on one task at a time. One

cannot think while paying complete attention to the breath at the same

time. With practice, the brain’s capacity to hold attention will gradually

increase.

When you first try to observe the breath, it is normal for the mind to

wander. As soon as you notice this happening, gently bring your attention

back to the breath. In time, and with regular attention to your breathing

patterns, the mind will wander less and less. This is valuable feedback

that your capacity to hold your attention on a task without distraction is

improving. Having a greater ability to concentrate will lead to improved

mental performance during all activities, including sports.

Wearing the SportsMask and practicing the exercises in this manual

naturally brings attention to the breath and offers a unique way to improve

concentration. With attention on the breath, the mind is not thinking of

the past or the future. Instead, the mind is focused on present moment

awareness. Since being in the zone involves complete attention on the

present moment, regularly focusing on the breath throughout the day

offers athletes a means to enter this coveted state at will.

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To date, researchers have recommended the practice of present

moment awareness as a means of reaching the zone and achieving peak

performance.

This technique of following the breath is at the core of most forms of

meditation, including the oldest form of Buddhist meditation, Vipassana,

which has been practiced for approximately 2,500 years. Psychology

researchers investigated the benefits of meditation by studying the

performance of meditators and non-meditators in a “Stroop” test, which

determines how quickly and accurately participants can focus on a specific

task while avoiding distractions. The test involves participants being

shown a series of color names. Each word is a different color to the one

it represents. For example, the word red might appear in the color blue.

Participants are shown a series of 120 mismatched words and colors over a

period of two minutes, and the objective is to name the color of the word,

not the word itself. The study showed that people who meditated not only

answered more questions, but they also made fewer errors. The paper

concluded that “mindfulness is linked to reduced errors across measures,

suggesting greater attentional control, carefulness, cognitive flexibility

and quality of performance. These results support the hypothesis that

mindfulness would correlate positively with task performance.”

As I often say to my students, focused attention on the breath is never

a waste of time. It is food for the mind, increasing awareness, improving

concentration and honing focus. Wearing the SportsMask enables you

to exercise while simultaneously experiencing greater present moment

awareness. Follow your breath as it enters and leaves your body and take

a break from the constant distraction of thought. Tame your mind and

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Class 3 References

Byrne-Quinn, E., Weil, J., Sodal, I., Filley, G. and Grover, R. (1971). Ventilatory control in the athlete. Journal of Applied Physiology, 30(1), pp.91-98.

Martin, BJ., Sparks., KE, Zwillich., CW, Weil., JV. (1979) Low exercise ventilation in endurance athletes. Med Sci Sports. 11(2), pp.181-185.

McArdle, W., Katch, F. and Katch, V. (2009). Exercise physiology: Nutrition, Energy, and Human Performance. 1st ed. Lippincott Williams & Wilkins, p.289.

McGurk, S., Blanksby, B. and Anderson, M. (1995). The Relationship of Hypercapnic Ventilatory Responses to Age, Gender and Athleticism. Sports Medicine, 19(3), pp.173-183.

Miyamura M, Hiruta S, Sakurai S, Ishida K, Saito M. (1998). Effects of prolonged physical training on ventilatory response to hypercapnia. The Tohoku Journal of Experimental Medicine, 156(Suppl), pp.125-135.

Nishino, T. (2009). Pathophysiology of dyspnea evaluated by breath-holding test: Studies of furosemide treatment. Respiratory Physiology & Neurobiology, 167(1), pp.20-25.

Scoggin, C., Doekel, R., Kryger, M., Zwillich, C. and Weil, J. (1978). Familial aspects of decreased hypoxic drive in endurance athletes. Journal of Applied Physiology, 44(3), pp.464-468.

Stanley, N., Cunningham, E., Altose, M., Kelsen, S., Levinson, R. and Cherniack, N. (1975). Evaluation of breath holding in hypercapnia as a simple clinical test of respiratory chemosensitivity. Thorax, 30(3), pp.337-343.

Woorons, X., Mollard, P., Pichon, A., Duvallet, A., Richalet, J. and Lamberto, C. (2008). Effects of a 4-week training with voluntary hypoventilation carried out at low pulmonary volumes. Respiratory

Physiology & Neurobiology, 160(2), pp.123-130.

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PROGRAM BASED ON BOLT SCORE, AGE AND STATE OF HEALTH

BOLT Score Lower Than Ten Seconds

Measure your BOLT score each morning after waking.

Breathe through the nose both day and night (wear MyoTape).

Practice the small breath-holds (Exercise 1) for ten minutes, six times

per day.

Small paces: (Exercise 3) Exhale through your nose, then pinch your

nose with your fingers and walk while holding your breath for five to ten paces. Rest for 30 seconds to one minute and repeat ten times.

Complete three sets per day.

Engage in ten to fifteen minutes of slow walking each day with your mouth closed. If you need to breathe through your mouth, slow down

or stop.

When your BOLT score increases to fifteen seconds, practice Breathe Light (Exercise 2) for one hour per day in six ten-minute sets.

As your BOLT score increases, it will become a lot easier to engage

in physical exercise. Your expected progress is to increase your BOLT

score to twenty-five seconds within six to eight weeks.

BOLT Score Between Ten and Twenty Seconds


Breathe through the nose at all times. Wear MyoTape at night.

Regularly observe your breathing throughout the day.

Breathe Light (Exercise 2) for ten minutes by three times daily.

Practice Breathe Light walking (Exercise 5) for between thirty and sixty minutes per day.

BOLT Score of Twenty Seconds or More


Breathe through the nose both day and at night, including wearing

MyoTape during sleep.

Breathe Light (Exercise 2) for ten minutes twice per day.

Breathe Light during a jog or run for thirty to sixty minutes.

After physical exercise, practice slowing down your breathing with

lateral expansion and contraction of the lower ribs.

CHAPTER 4

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TAILORING EXERCISES TO INDIVIDUAL ATHLETES

Persons who suffer from migraines, panic attacks, anxiety, heart disease (if

there has been a recent heart attack, use relaxation without air shortage) or

high blood pressure may experience stress from holding the breath.

Over the years, many children and adults with low BOLT scores, severe

asthma, labored breathing or panic disorders have made progress by

practicing Exercise 3; holding the breath while walking for between five and ten paces. The objective of this exercise is for the student to challenge

themselves, but to have complete control of their breathing following

the breath-hold. When breathing is labored, as in the event of an asthma

attack, one must be careful not to destabilize the breathing as this will

exacerbate the symptoms.

PREGNANCY

Please advise females attending your training not to do any of the

breathing exercises if they are (or are likely to be) in the first trimester of pregnancy. This information is contained in the client intake form.

However, also mention it in class that, if pregnant, the expectant mother

should never do strong breath-holds as this will create a lot of stress for

both mother and baby. If a student is pregnant, discuss the importance of

avoiding over-breathing by not overeating, managing stress, relaxing, and

by breathing through the nose, etc. During any stage of pregnancy, the

BOLT should not increase by more than two seconds each week. For the

second trimester onward, only teach nasal breathing and gentle relaxation

with light air hunger.

MEDICATION

When the morning BOLT score increases to above twenty seconds, persons

taking medication for hypertension, diabetes or thyroid should visit their

medical doctor to have their medication evaluated. An improved BOLT

score, reduction in respiratory rate, improved sleep and lighter breathing

can all help to improve the functioning of the autonomic nervous system,

leading to improved health and reduced need for medication. In addition,

cadence breathing to a pace of 5.5/6 breaths per minute can help restore

normal autonomic functioning.

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Traditionally, thousands of children and adults with asthma and rhinitis have

benefitted from the Breathe Light and breath-holding exercises. Symptoms such as coughing, wheezing, exercise-induced asthma, disproportionate

breathlessness and nasal obstruction will continue as long as the BOLT

score remains less than twenty-five seconds.

NASAL OBSTRUCTION RESULTING IN STRONG AIR HUNGER

If a student has a long history of rhinitis (nasal obstruction), then they may

feel air hunger during rest and most certainly during physical exercise

when they first switch to nasal breathing. The feeling of air hunger is due to an accumulation of carbon dioxide. When the student has a strong

chemosensitivity to carbon dioxide build-up (low BOLT score), they will

likely exhibit a fast respiratory rate with excessive breathing volume. In

addition, stuffiness of the nose will create resistance to breathing, which will also cause air hunger.

The feeling of air hunger will continue until breathing becomes lighter and

the nasal obstruction of the nose reduces. The best exercise to open the

nose and alleviate the feeling of air hunger is holding the breath until a

strong air shortage is created. Ideally, an adult should hold their breath for

at least thirty seconds to help decongest the nose.

Make sure that your student is suited to doing strong breath-holds and

practice the nose unblocking exercise. A video demonstration is available

from the training portal. (five reps three times daily).

If the student has a mildly congested nose at night, then first clear the nose by practicing the nose unblocking exercise and rinsing the nose with

saline solution. It is very important that students with a history of nasal

obstruction wear tape to help restore nasal breathing during sleep. While

wearing the tape, the nose will never completely block. In any event,

MyoTape does not cover the lips and allows mouth breathing in times of

emergency. The student will continue to experience symptoms of nasal

obstruction and a stuffy and runny nose until their BOLT score is at least

twenty five seconds.

If the student has an uncomfortably congested nose at night, then it

is helpful to follow the same instruction as above and also to wear a

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nasal dilator during sleep and physical exercise. Nasal dilators will help

overcome the feeling of suffocation during sleep.

The vast majority of students are able to switch from mouth breathing to

nose breathing permanently. For students with a severely deviated septum

or nasal polyps, practice five repetitions of the nose unblocking exercise to create a strong air hunger. Then check if the student (child or adult) can

breathe through their nose for one minute. If the child or adult is unable to

breathe through their nose for one minute following correct application of

the nose unblocking exercise (five reps to create strong air hunger), then request that they visit their family doctor to get medicine to decongest

the nose. In addition to using medication, it is also very important that

the student practices the techniques of the Oxygen Advantage® and

breathes through the nose both during wakefulness and sleep. This way,

the need for nasal medication can be reduced over time as the BOLT score

improves.

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TRAINING FORMAT WEEK ONE TO WEEK FOUR ONWARD

Week 1

It is important that the student completes the client intake form (available

from the training portal) as this will provide information on the student’s

breathing, BOLT score and state of health.

Who is the client?

Approximate age?

State of health?

What would they like to achieve?

Is it a team or an individual?

The sportier the client, the greater the emphasis on physical

movement.

What form of physical exercise do they partake in? The Oxygen

Advantage® can be applied during walking, running, cycling, rowing or

any sport.

Are they recreational or competitive?

How do they warm up?

Do they meditate?

Incorporate the OxygenAdvantage® into the student’s existing routine

for best effect. During the first class, discuss the benefits of functional breathing and how to measure it using BOLT. Talk about the Bohr Effect,

nasal breathing, sleep, asthma, reduced breathlessness, improved focus

and concentration.

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Pay attention to your student’s breathing during rest.

Is it:

Fast or slow?

Regular or interspersed with sighs?

Is there a pause at the end of exhalation?

Upper chest or diaphragm?

Observe amplitudes of the breath.

Measure the student’s BOLT score and give feedback. Ultimately, the BOLT

score provides feedback on functional breathing and onset and endurance

of breathlessness during physical exercise.

Practice the following exercises during the first class: Exercise 2: Breathe Light Biochemical: (2 to 3 sets of four minutes)

Tape the mouth at night using MyoTape or LipSeal Tape

Week 1 homework

Breathe Light for fifteen minutes during the day and fifteen minutes

before sleep (sets of five minutes with rest of one minute between

each).

Incorporate nasal breathing and reduced volume breathing during

warm-up.

Nose breathing during physical exercise as much as possible.

Week 2

Check your student’s progress. Did they wear the tape during sleep

and practice their exercises during training and at rest? Observe how

the student breathes as they enter your class. Is their mouth open or

closed?

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A typical routine during Class 2 is as follows:

Recap on functional breathing and dysfunctional breathing

Measure BOLT score

Exercise 1: Many small breath holds (5 minutes)

Exercise 2: Breathe Light Biochemical: four minutes

Exercise 2: Breathe Light Biomechanical: four minutes

Exercise 4: Walking: five minutes

Week 2 homework

Breathe Light for fifteen minutes during the day and fifteen minutes before sleep.

Incorporate nasal breathing during warm-up for physical activity.

Nose breathing during physical exercise as much as possible.

Week 3 onward

A typical routine during Class 3 is as follows:

Recap on functional breathing and dysfunctional breathing

Measure BOLT score

Exercise 1: Many small breath holds (5 minutes)

Exercise 2: Breathe Light Biochemical: four minutes

Exercise 2: Breathe Light Biomechanical: four minutes

Exercise 2: Breathe Light Paced: four minutes

Exercise 4: Walking: five minutesExercise 5: Walking, jogging/fast walking: five minutesExercise 6: Breathe Light Advanced (5 minutes)

Functional breathing is not a technique. It’s a way of life. Incorporate

into rest, sleep and physical exercise.

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TEACHING THE OXYGEN ADVANTAGE®

The Oxygen Advantage® program can be taught in a number of ways:

Incorporated into an existing training program. In doing so, please

ensure that your students know that the exercises being used are from

the Oxygen Advantage®.

Four to six sessions of either one-to-one training or to small groups of

up to ten people.

Half-day training

Content covered during the half-day format

Measure BOLT score

Practical Exercise 2: Breathe Light (all variations)

Practical Exercise 4: Breathe Light: walk

Practical Exercise 5: Breathe Light: walk, jog

Sleep, incorporating the exercises into your way of life

Practical Exercise 6: Breathe Light Advanced (5 minutes)

Physical Exercise, sleep, incorporating the exercises into your way of

life

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Class 4 References

Amann, M. (2012). Pulmonary system limitations to endurance exercise

performance in humans. Experimental Physiology, 97(3), pp.311-318.

Beales, D., O’Sullivan, P. and Briffa, N. (2010). The effect of increased

physical load during an active straight leg raise in pain free

subjects. Journal of Electromyography and Kinesiology, 20(4), pp.710-718.

Chaitow, L., Gilbert, C., Bradley, D. & Morrison, D. (2013). Recognizing

and Treating Breathing Disorders: A Multidisciplinary Approach (2nd ed.).

Churchill Livingston: Elsevier Health Sciences.

Cross, T., Breskovic, T., Sabapathy, S., Maslov, P., Johnson, B. and Dujic, Z.

(2013). Respiratory Muscle Pressure Development during Breath Holding in

Apnea Divers. Medicine & Science in Sports & Exercise, 45(1), pp.93-101.

De Troyer, A., Estenne, M., Ninane, V., Van Gansbeke, D. and Gorini,

M. (1990). Transversus abdominis muscle function in humans. Journal of

Applied Physiology, 68(3), pp.1010-1016.

De Troyer, A., Leeper, J., McKenzie, D. and Gandevia, S. (1997). Neural drive to the diaphragm in patients with severe COPD. American Journal of

Respiratory and Critical Care Medicine, 155(4), pp.1335-1340.

Griffiths, L. and McConnell, A. (2006). The influence of inspiratory and expiratory muscle training upon rowing performance. European Journal of

Applied Physiology, 99(5), pp.457-466.

Hodges, P. and Gandevia, S. (2000). Changes in intra-abdominal pressure

during postural and respiratory activation of the human diaphragm. Journal

of Applied Physiology, 89(3), pp.967-976.

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Johnson, M., Sharpe, G. and Brown, P. (2007). Inspiratory muscle training improves cycling time-trial performance and anaerobic work capacity but

not critical power. European Journal of Applied Physiology, 101(6), pp.761-

770.

Karaula A, D., Homolak, J. and Leko, G. (2016). Effects of hypercapnic-hypoxic training on respiratory muscle strength and front crawl stroke

performance among elite swimmers. Turkish Journal of Sport and Exercise,

18(1), pp.17-24.

Key, J. (2013). ‘The core’: Understanding it, and retraining its dysfunction. Journal of Bodywork and Movement Therapies, 17(4), pp.541-

559.

Lehrer PM, Vaschillo E, Vaschillo B. (2000). Resonant frequency

biofeedback training to increase cardiac variability: rationale and manual

for training. Applied Psychophysiology and Biofeedback. 25(3), pp.177-91.

Lehrer, P. and Gevirtz, R. (2014). Heart rate variability biofeedback: how

and why does it work?. Frontiers in Psychology, 5.

McConnell AK, Romer LM. (2004) Respiratory Muscle Training in Healthy

Humans: Resolving the Controversy. International Journal of Sports

Medicine, 25(4), pp.284-293.

McConnell, A. (2011). Breathe strong, perform better. Champaign, IL:

Human Kinetics.

Noakes, T. (1991). Lore of running. Champaign, IL: Human Kinetics.

Pedersen, B. and Saltin, B. (2015). Exercise as medicine – evidence

for prescribing exercise as therapy in 26 different chronic

diseases. Scandinavian Journal of Medicine & Science in Sports, 25, pp.1-

72.

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Porges S. W. (1986). “Respiratory sinus arrhythmia: physiological basis,

quantitative methods, and clinical implications,” in Cardiorespiratory and

Cardiosomatic Psychophysiology, eds Grossman P.

Ramsook, A., Koo, R., Molgat-Seon, Y., Dominelli, P., Syed, N., Ryerson,

C., Sheel, A. and Guenette, J. (2016). Diaphragm Recruitment Increases during a Bout of Targeted Inspiratory Muscle Training. Medicine & Science in Sports & Exercise, 48(6), pp.1179-1186.

Romer, L., McConnell, A. and Jones, D. (2002). Inspiratory muscle fatigue in trained cyclists: effects of inspiratory muscle training. Medicine & Science in Sports & Exercise, 34(5), pp.785-792.

Russo, M., Santarelli, D. and O’Rourke, D. (2017). The physiological effects

of slow breathing in the healthy human. Breathe, 13(4), pp.298-309.

Trembach, N. and Zabolotskikh, I. (2017). Breath-holding test in evaluation

of peripheral chemoreflex sensitivity in healthy subjects. Respiratory

Physiology & Neurobiology, 235, pp.79-82.

Urmey, W., De Troyer, A., Kelly, K. and Loring, S. (1988). Pleural pressure

increases during inspiration in the zone of apposition of diaphragm to rib

cage. Journal of Applied Physiology, 65(5), pp.2207-2212.

Wagner, W., Breksa, A., Monzingo, A., Appling, D. and Robertus, J. (2005). Kinetic and Structural Analysis of Active Site Mutants of Monofunctional

NAD-Dependent 5,10-Methylenetetrahydrofolate Dehydrogenase

fromSaccharomycescerevisiae†. Biochemistry, 44(39), pp.13163-13171.

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FLIP CHART NOTES

Exercise 2a Breathe Light Biochemistry

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Exercise 2a,b,c Breathe Light

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Breathing, Sleep, Emotions

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Increase to Baroreceptor Sensitivity Reduces Chemosensitivity

invincible breathingtm · we will concentrate on achieving air hunger only. don’t be concerned...

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